Common Surgeries Performed on Exotic Companion Mammals Peter G. Fisher, DVM, DABVP (Exotic Companion Mammal) Pet Care Veterinary Hospital, Virginia Beach, VA, USA

FERRETS Adrenal Disease A ventral midline incision is made 1–2 cm caudal to the xiphoid process and extended caudally beyond the umbilicus to allow good visualization of the cranial and mid . A complete exploration of the abdomen should be performed to rule out metastasis, insulinoma, or other concurrent disease. It is ideal to visually and palpably inspect both adrenals before deciding on whether to resect either one or both. The left gland is more accessible, and may be found embedded in the fat and connective tissue cranial to the left . To visualize the left adrenal gland, the spleen and much of the small intestines must be gently exteriorized and kept moist with warm isotonic saline during the surgery. In cases of less obvious adrenal enlargement gentle manipulation will allow location by palpation. Careful blunt and sharp dissection around the adrenal gland will allow more complete visualization of the gland and its blood supply. Cotton tipped applicators and Metzenbaum scissors may be used in conjunction for blunt and sharp dissection respectively in order to tease the adrenal away from the surrounding fat. Vascular clamps [Weck Hemoclips®, Teleflex Medical, RTP, NC] are essential in ligation of the fine adrenal vasculature. The right adrenal gland is cranial and medial to the right kidney, and is more difficult to excise due to its frequent adherence to the vena cava and location just dorsal to the caudate lobe. The hepatorenal must be transected and the caudate lobe elevated to expose the gland. Extreme care must be taken to avoid damage to the vascular lamina as the gland is essentially “teased” away from the vena cava. Cotton-tipped applicators can work well for this. The neonatal Statinsky or DeBakey cardiovascular clamp may used to occlude the caudal vena cava while the right adrenal is being resected. Even when performed by experienced surgeons, portions of the right adrenal or its capsule may remain due to its adherence to the vena cava. Debulking the adrenal or opening the adrenal capsule and shelling out the contents may be all that is possible without risking serious damage to the vena cava. Many times a hemostatic clip may be placed between the adrenal and the vena cava, thus allowing its removal. Each surgery will vary according to the size and position of the diseased adrenal gland. For control of minor hemorrhage hemostatic material such as Surgicel® (Ethicon Inc., Somerville, NJ) or Vetspon® (Novartis Animal Health, Greensboro, NC) may be used. Small lacerations in the vena cava can be sutured with 7-0 or 8-0 nylon. Alternatively a 2-surgery technique (Driggers) has been advocated for right adrenal gland resection. The first surgery uses a 5 mm Ameroid constrictor ring (Research Instruments NW INC, Lebanon, OR) placed just distal to the adrenal gland around the vena cava, which allows for slow constriction of the vena cava while stimulating gradual collateral circulation by the hepatic portal system. The second surgical procedure is performed 1–3 months later giving time for collateral circulation to develop. Careful dissection of the Ameroid ring, the vena cava and attached adrenal gland allow for en bloc removal. Insulinoma Clients need to be aware that it is unlikely that surgery will cure insulinoma, and to what degree it slows progression of clinical signs, and the need for additional medical therapy, depends on the degree of pancreatic involvement and metastasis. An indwelling IV catheter is placed preoperatively and the ferret is infused with maintenance fluids with added 5% dextrose. The ferret pancreas is found along the proximal duodenum and has a right (duodenal) and left (splenic) limb. During surgery both lobes of the pancreas are examined visually and manually. Palpate the entire pancreas gently between two fingers to detect very small nodules that may be single, multiple or diffuse, and range from grossly invisible up to 2 cm in size. Solitary tumors can be resected with blunt dissection; using hemostatic clips to ligate vasculature. Partial pancreatectomy of the left (splenic) pancreatic limb is recommended in cases where a distinct insulinoma nodule cannot be found and infiltrative carcinomatous micro-metastasis throughout the pancreas is suspected. Hemostatic clips or several crushing ligatures are effectively used to separate the left and right pancreatic limbs. Close defects to prevent visceral entrapment. The liver, spleen, adrenal glands and mesenteric lymph nodes are examined for abnormalities before closing. Gastrointestinal Surgery Indications include GI foreign body or hairball removal, neoplasia and inflammatory bowel disease (IBD). Gastrointestinal surgery is similar to the cat. Gastrotomy incisions are made in the greater curvature. Close gastric wall with 4-0 absorbable suture (4-0 PDS or Monocryl, Ethicon Inc, Somerville, NJ)) in a Cushing-Lembert pattern staying close to incision site so as not to incorporate an inordinate amount of tissue. Close enterotomy incisions using 4 to 5-0 absorbable suture in a simple interrupted pattern - again try to incorporate a minimum of tissue so as not to narrow the intestinal lumen. Biopsies of stomach, duodenum, jejunum are indicated to make a diagnosis of Inflammatory Bowel Disease (IBD) and certain neoplasias (lymphoma most common). Stab incisions are made in the stomach great curvature and intestinal anti-mesenteric surface and 1–2 mm by 5 mm full thickness (make sure to include mucosa) samples are taken and close as for gastrotomy or enterotomy. Nephrectomy Indications in ferret include hydronephrosis (most commonly secondary to inadvertent ligation of the ureter during OVH), renal neoplasia and some cases of renal cystic disease. A mid abdominal midline incision is made. The kidney is isolated and the over the caudal pole of the kidneys is grasped with forceps and incised with scissors. The surgeon expands this incision with combination of digital dissection and scissors to peel away the peritoneal adhesions over the kidney. Dissection is continued until the kidney is free except for attachment of renal artery, vein and ureter. These are ligated individually or together with Hemoclips® or 4-0 absorbable monofilament suture. The kidney is then removed. Incised retroperitoneum is usually left open. Check for hemorrhage and close abdomen routinely.

RABBITS AND GUINEA PIGS Rabbit Ovariohysterectomy Rabbits can be spayed any time after 4 months of age. Ovariohysterectomy is indicated in all female rabbits to prevent pregnancy, control territorial aggression and urine marking associated with sexual- related behavior, and prevent uterine neoplasia (very common), pyometra or endometrial venous aneurysms. A 2–3 cm midline incision is made approximately 2 cm caudal to the umbilicus. Subcutaneous fat is bluntly dissected away and the linea identified. The linea is gently grasped and elevated with thumb forceps as a stab incision is made into the abdomen. A spay hook is usually not necessary as the lies dorsal to the cranial pole of the bladder and is easily identified and lifted through the incision using forceps. With gentle traction, the uterus is followed to the oviduct and infundibulum that are coiled in a large loop several times longer than that of the dog or cat. The of the doe is a primary site of fat storage and many times the are embedded in a large fat pad. Gentle digital manipulation and traction will allow identification of the which is isolated with its vasculature for ligation. There are multiple vessels associated with the ovary which are double-ligated (together) with transfixing and cerclage sutures of an absorbable suture such as 3-0 Monocryl, Bisosyn or Vicryl. Care is taken to ensure the oviduct is removed in its entirety. The procedure is repeated for the opposite ovary. The uterus is now isolated and the body can be ligated cranial or caudal to the cervices. The author prefers to ligate and resect the uterus close to the cervix - just on the vaginal side of the cervix. Closure of the abdomen with 3-0 monofilament absorbable suture is routine: Simple interrupted pattern in linea, followed by simple continuous patterns in SubQ and intradermal. Rabbit Castration Indications for rabbit castration include control of urine marking behavior, minimization of territorial aggressive behavior, prevention of reproduction and testicular tumors. Both prescrotal and scrotal techniques have been described. The author prefers a prescrotal incision as it is neater and is not associated with the complication of scrotal edema. A 1.5 cm incision is made on the midline just cranial to the scrotum similar to a skin incision for canine castration. One of the testicles is manipulated toward the incision by applying digital pressure on the scrotum. If testicles are withdrawn into the abdomen, gentle pressure is applied to the abdomen to return testicles to their normal position. The connective tissue and fat are dissected away with hemostats to expose and isolate vaginal tunic. The vaginal tunic is lifted up and the caudal ligament of the testicle is carefully torn from its scrotal attachment, freeing the testicle and spermatic cord. Gauze squares and traction will aid this procedure. Gentle pressure is applied to the abdomen to ensure the testicle is isolated to the caudal aspect of the spermatic cord. The spermatic cord is clamped proximal to the testicle and close to the inguinal ring. The spermatic cord is double ligated, using 3-4-0 non absorbable suture, transfixed and resected. The procedure is repeated on the opposite side. Closure of the subcutaneous tissue with a simple continuous pattern is followed by a continuous intradermal skin closure. Guinea Pig Ovariohysterectomy Indications include: female guinea pigs can become sexually active as early as 8–12 weeks of age, cystic ovaries of varying degrees of size and hormonal influence, pregnancy toxemia and dystocia are all common in older females. Neoplasia and pyometra are uncommon but can occur. Technically guinea pig ovariohysterectomy is similar to the rabbit with several exceptions: 1) The ovaries are supported by a short making the ovary more difficult to exteriorize than rabbits or carnivores. Initial skin incision is ideally made over the umbilicus and extends caudally 2–3 cm. It may be necessary to extend the incision cranially to avoid accidentally tearing the fragile, fat-filled suspensory ligament. 2) Hemostatic clips versus suture may make for easier ovarian pedicle ligation. 3) It is recommended to ligate the uterus just cranial to the cervix. In most cases, 2 transfixing sutures incorporating the uterine blood vessels are adequate. Alternatively an ovariectomy via a dorsal lumbar approach is preferred by many exotic mammal surgeons. Female guinea pigs are not the hardiest of surgical candidates making superior peri-operative care imperative. Guinea Pig Castration Castration can be performed by a closed or open technique. The author prefers a closed technique where the testicles are removed through two separate incisions over each scrotum. If either testicle is in the abdomen, gentle abdominal pressure will return the testicle to the scrotum. A 1–2 cm incision is made through the middle of the scrotum parallel to the penis. Care is taken not to penetrate the tunica vaginalis. Keep in mind that an inadvertent incision into the tunic may occur while incising over the scrotum creating an open situation. If this occurs, the tunic surrounding the spermatic cord and vas deferens can be grasped more proximally and double ligated in a closed fashion. Grasp the tunic and remove the testicle from the scrotum and gently dissect the tunic from its attachment circumferentially. When the testicle is isolated, apply traction and gently strip the fascial attachments using a gauze square. This allows the testicle to be exteriorized and the spermatic cord isolated proximally. Ligate the cord using a two or three clamp technique and double ligate with transfixing absorbable suture material. Sutures are placed close to the inguinal ring without excessive pulling of the spermatic cord. It is not necessary to remove the epididymal fat pad and leaving it in place may prevent herniation. The technique is repeated on the opposite testicle. Several simple interrupted (or a short continuous) subcutaneous sutures are utilized to appose overlying tissue followed by an intradermal closure in each scrotum. Mammary Gland Tumors in Guinea pigs A retrospective study of pigs with mammary tumors found that males and females were equally represented, but that those tumors found in males were more likely to be malignant vs. benign. Benign hyperplasia was the more likely diagnosis in those female pigs with mammary gland enlargement. No data was available on chemotherapy for those malignant tumors. This information may be used in educating clients on prognosis associated with surgical correction of this disease. In general surgical mastectomy is straight forward in the guinea pig, however wide surgical margins are difficult to obtain due to the size of the patient. Cystotomy Calcium carbonate and calcium oxalate cystic calculi are most common in guinea pigs and rabbits. Magnesium ammonium phosphate and cysteine calculi are most common in ferrets. Definitive causes of cystic calculi are largely unknown with nutrition, anatomy, genetics, water intake, environment, and infection all possibly playing a role. Clinical signs associated with cystic calculi include hematuria, stranguria, dysuria, incontinence, and bruxism secondary to abdominal pain. Cystotomy is technically similar in all small exotic mammals. Placement of an urinary catheter is ideal, esp.in males with multiple small calculi) using a “Slippery Sam” 3.5 Fr Tomcat Urethral Catheter (Smiths Medical, Waukesha, WI). Surgical approach is via a ventral midline incision just cranial to the pubis. Exteriorize bladder and isolate with saline moistened gauze squares. Make a 5–10 mm incision in ventral bladder wall, beginning at the apex. Samples are taken for culture and sensitivity (calculus itself, mucosal swab or piece of excised bladder wall). Remove calculi and flush bladder with warmed normal saline. If urinary catheter placed- flush retrograde. If urinary catheter not placed pre-op you may pass urinary catheter normograde and flush small stones back into bladder for removal. Close bladder wall with 4-0 to 5-0 absorbable monofilament suture in a continuous inverting pattern (author uses Cushing-Lembert) taking care not to penetrate mucosa. Flush surgical site. Keep in mind that the bladder wall of guinea pigs and rodents is particularly thin. Return bladder to abdomen and close abdomen routinely.

RATS Rat Mammary Tumors Anatomically, mammary gland tissue in the rat extends on either side of the ventral midline from the axillary to the inguinal regions, and mammary gland tumors may occur anywhere in this area. Benign mammary fibroadenoma represents approximately 85–90% of all mammary tumors in the rat and are extremely common. Overall, the biological behavior is benign; the neoplasms can become very large, ulcerate, and infiltrate locally, but they rarely metastasize. For this reason, surgical excision is generally curative, however, additional fibroadenomas may develop in remaining mammary tissue. Surgical removal is straightforward. Due to patient size and benign nature of these tumors wide margins are not taken. An elliptical incision is made around the mass. The mass is undermined and resected without penetrating the tumor capsule. In general these tumors have limited attachments to surrounding tissue. In spite of their large size, and the limited vascular supply can easily be ligated with vascular clamps (Hemoclips®) or suture material. Once removed the dead space and subcutaneous tissue is closed with 3- 0 to 4-0 absorbable monofilament in a simple interrupted or continuous pattern (or in combination depending on size of space to be closed). The skin is closed in a continuous intradermal suture pattern. Tissue adhesive is added to seal any remaining gaps along the incision line.

REFERENCES 1. Bartlett L, Lightfoot T. Ferret surgeries. The Exotic Guidebook, Exotic Companion Animal Procedures. Lake Worth: Zoological Education Network; 2005:1–32.

Beeber N. Abdominal surgery in ferrets. Bennett A, ed. Veterinary Clinics of North America, Exotic Animal Practice. 2000;3(3):647–662. Driggers T. A novel surgery for right-sided adrenalectomies in ferrets (Mustelo putorius furo). Proceedings of the Association of Exotic Mammals Veterinarians Scientific Program. Savannah. 2008:107–109. Fisher P. Surgical removal of rat mammary tumors. Exotic DVM. 2002;4(2):6. Gibbons, P, Garner M. Mammary gland tumors in Guinea pigs (Cavia porcellus). Proceedings of the Association of Exotic Mammal Veterinarians. Milwaukee. 2009:83. Jenkins J. Surgical sterilization in small mammals: spay and castration. Bennett A, ed. Veterinary Clinics of North America, Exotic Animal Practice. 2000;3(3):617–627. Johnson-Delaney K. Ovariohysterectomy in a rat. Exotic DVM. 2002;4(4):17–21. Mullen H. Nonreproductive surgery in small mammals. Bennett A, ed. Veterinary Clinics of North America, Exotic Animal Practice. 2000;3(3):629–645. Quesenberry K, Carpenter J. Ferrets Rabbits and Rodents, Clinical Medicine and Surgery. 3rd ed. Saunders; 2011.

Communication in the Digital Age Eric Garcia Simply Done Tech Solutions, LLC Tampa, FL, USA The latest enhancements in technology are forever changing the way we communicate. Although it has become easier and more efficient for us to communicate, there is still a mindset that is withholding the willingness to adapt to all of the advances in communication. There are several reasons for the hesitation to jump on board with new technology. For instance, there is the cost factor and return on my investment factor. At times we are unsure if using new methods of technology make client interaction less personal. It is very true to say there are many things to think about before getting on board with a new method of communication with clients. However, it is also very true that the longer you wait the potential of getting new clients, generating higher revenue and the satisfaction of your clients’ needs will be slow to rise. In our practices today we are seeing a new generation of clients who demand and crave a change in the way we communicate. Starting with Generation X who was exposed to the start of the .COM era or in basic terms “the start of the Internet”. The very start of online communication was initially slow getting started and adapting to. At the time having this “luxury” was not easily affordable at home or in the work place. Time elapsed and we started to see prices drop and even more enhancements come along with the rise of the Net Generation also known as Generation Y. The affordability of the computer and Internet at home made it easier for this generation to heavily rely on it as a resource and a convenient form of communication. With computers getting smaller and becoming part of our phones, it made it has made it easier for us to stay connected online wherever we are at. It is easy to see that our current generation was exposed to online communication for a majority of their lives and prior generations are quickly catching on. It’s time to focus on the specifics of how our clients are communicating on the web.

ONLINE PATIENT PORTAL Let’s start off by understanding what an online patient portal is. An online patient portal communicates information from your practice management software into an online secure patient portal. Information that is transmitted usually consists of the patient’s name, birthdate, reminder dates, prescriptions recently filled and great educational material. Depending on whom you choose as your online patient portal provider will depend on the information transmitted online. Clients register for their online patient portals by registering online via the clinic website or by inputting an email address into the client’s electronic file. Once your client registers and accesses the portal they will see their pet’s up to date information. The benefits of an online patient portal greatly exceed the total cost. Clients who have access to an online patient portal help increase the compliance percentages in your practice. They are able to see when their pet is due for services and read about the importance of the service due all in one place 24 hours a day 7 days a week. Reminders are automatically sent to the client’s email address on file. Prescriptions are listed allowing clients to easily request a refill reminder by email and even request the refill online. An online patient portal is full of other fun features for clients. They can upload photos, blog with other pet owners, read about pet care and more. By having an abundance of information on the patient portal for clients to view you are increasing the likelihood of the number of visit. Your practice name and information is made prominent throughout the portal so clients can familiarize themselves with you and your practice.

EMAIL REMINDERS It is difficult to think that 100% of all mail makes it to its desired destination. An incorrect address can be the key reason for mail being delivered to the wrong destination. A majority of practices still rely on the postal services to deliver reminder cards to their clients. There is a good reason why. Statistics show the return rates on post cards are still very high. It is not recommended to remove post card mailings in your practice. However, with our new generation of clients relying on e-mail as their primary form of communication, it is important to implement an e-mail reminder protocol for your practice. If the reminder post card never makes it to the client the probability of that client coming in to satisfy their reminders start to decrease. Even though pets are a priority in households across America they still rely on you to remind them of what medical attention their pet(s) needs. To implement e-mail reminders in your practice start off by contacting your practice management software technical support team to see if there is a feature already offered to you at no additional cost. If not, consider moving toward a patient portal where clients will greatly benefit from not only e-mail reminders but a variety of other online services. Finally, if all else fails consider getting started with your own method of e-mail reminders. Start off by contacting an e-mail messaging provider. Talk to your practice management software technical support team about extracting reminders and client e-mail addresses in one file excel file. This file can easily be uploaded into the e-mail messaging provider’s database and sent out as an e-mail reminder.

PROPERLY IMPLEMENTING EMAIL COMMUNICATION Have you decided if another great way to communicate with clients is by email because of it being most convenient for your client? If so, you are taking a great step forward to adapting to our new generation of client’s preferred way of communicating. The need to understanding how to properly communicate with pet owners using email is extremely important for formality and legal reasons. Like any important information you communicate verbally to clients you start by documenting it in the pet’s medical record. Make sure you are using a branded or professional email address. You don’t want to communicate with clients using an email that is intended for personal reasons or that is too creative ([email protected]). Try setting up branded email with your web hosting company. If you do not have a website, setup an email address with a reputable web company such as Google, Hotmail or Yahoo and keep it simple ([email protected] or [email protected]). When communicating do not use short phrases or terms only medical personnel tend to understand. Spell out exactly what you are trying to say so the client can understand it in an email. If you are not going to be sending the email yourself make sure whoever you rely on communicating this information for you is trust worthy and able to write a great amount of information with no errors. Make sure you keep each email that is sent and received in your inbox as this will serve as proof of communication. Any medical recommendations you make such as a new treatment route, change of treatment, medical dosage changes, should all be printed and put in the medical record. If you store your medical records electronically, print your email to a PDF printer and attach it to the patient file as a communication note. Make sure you check and reply to emails daily. If you do not check your email daily, see if you can enable an auto reply to all emails sent to you that explains you have a 5–6 hour reply turnaround time. Finally, as a major DO NOT in email communication... Do not allow your clients to use this to get out of a visit in your practice.

TEXTING Texting is yet another great way to communicate with your clients. However, you should know there are times when text messages are best used and there are times a phone call should be made instead. Below is a list of ways you can utilize text messaging in your practice: Dos Quick update on how a client’s pet is doing while boarding or dropped off for a surgical procedure: “Elvis is doing great Mr. Garcia! We will keep you updated.” “Elvis is recovering from his neuter nicely. We will call you soon!”

Quick reminder of a service becoming due or over due: “This is a reminder Elvis is due for his Bordetella vaccine! - Simply Done Vet Staff”

• “This is a reminder blood work is required before Elvis’ next medication refill.” Quick confirmation of a prescription filled: “Elvis’ meds are now ready to pick up.” Don’ts Full doctor update on how a client’s pet is doing while boarding or dropped off for a surgical procedure: “Elvis is getting ready to undergo anesthesia. We just put his catheter in and we have him hooked up on IV fluids. He is in his cage waiting to go next.” “We gave Elvis his vaccines and exam. Everything is normal except his left eye has some discharge so I’m going to prescribe an ophthalmic ointment to clear that right up. His blood work results came back a bit elevated and I suggest medication ABC to go home and be given tonight. Call me if with any updates.”

Abnormal blood work results: “Elvis’ liver enzymes came back elevated. I suggest we take an ultrasound and x- rays to work up the case more and find out the cause of it. In the mean time I have some medications up front for you to pick up when you are able to.”

SOCIAL MEDIA Social media can easily help to communicate with a variety of generations of clients. Websites like Facebook and Twitter easily link up together to share some of the same information making it a one stop communication shop. Information is easily transmitted to your client’s pages and phones (if they have the feature enabled). Having this steady stream of communication is key to keeping in touch with Generation X & Y clients. To properly implement a Facebook and Twitter page in your practice follow some of these basic rules. For starters, do not relay ANY medical information or information regarding the care and health of a patient on Facebook or Twitter. These websites are not intended for that purpose nor are recommended. Use these websites to market your practice to your current clients and potential new clients. Add a few photos of the practice and the bond with your staff and clients. In your information block add a mission statement or the values your practice was built on. A majority of this information and be copied and pasted right from your current website (if you do not have a website, do not use Facebook and Twitter as an alternative). Leave facts on your page that help educate clients and also lead to a question about a service you offer but don’t make it obvious. For example: “Wow! We just received “Kobe’s” DNA results back from the lab and it turns out he is mixed with a Yorkie and Maltese!”, then show a photo of the patient and ask “What mix do you think your dog is?!”. This will lead to dialogue on your page and possibly even have a client question if you offer DNA testing. I stress the importance of not making it seem obvious that you are making it known you offer a service. The last thing a client wants on their page is someone (especially their veterinarians office) trying to sell them into a service. Social media websites can help drive conversations with clients outside of their pet’s annual vaccination visits. You could even open the doors to clients’, friends and family adding you to their page creating a web of free advertising.

WEBSITE ON THE GO! We discussed how clients rely on the web as a primary method of communication. We know clients access the web on their mobile devices. So now discover why a mobile website is beneficial for your practice and clients. If you currently have a website it is most likely able to be accessed on a majority of mobile phone devices. What you may not know is the time it takes for a full blown website with high quality images to load on a mobile phone. The speeds of broadband internet on a mobile phone and a computer (depending on provider, service and type of internet connection) cannot yet be matched or slightly compared for the most part. This makes your website useless on a mobile phone for clients. A website designed for mobile use can be opened up in almost any phone browser that has internet AND at a much faster speed with no page zooming required. The mobile version of your website will have basic information about your practice such as: hours of operation, mission statement, services offered and a few contact pages. The mobile contact web pages are great for clients being able to request refills on prescriptions and put in appointment request times on the go! It makes it easier for your clients to do this when they are out and about or sitting somewhere waiting and playing on their phone. If they visit your website and find it takes forever to load, and is too complicated to navigate on a phone, they may move on. If they visit your website and see a mobile they will continue and proceed with further communication. Mobile websites are yet another thing you can do to make life easier for your clients and allow them to get in touch with you quicker.

DON’T BE THE ODD BALL OUT Don’t be the only practice in your area who does not offer these new methods of communication to your clients. Be one of the many practices in your area who offer these services. If you are the odd practice standing out and your competitors offer these services it won’t be too hard for a new generation client move in the opposite direction.