Vancouver Feline Hospital - Cat Veterinary Clinic

Marmalade was premedicated with a fentanyl patch the night before as pre-emptive pain control. Half an hour before surgery he was given glycopyrolate and dexamethasone by SQ injection and placed in the oxygen cage. Then we placed an IV catheter, and induced anaesthetic with ketamine and diazepam. He was intubated immediately and placed on oxygen and isoflurane to maintain anaesthetic. As I was clipping the surgery site, he received pre-emptive IV antibiotics. We moved him to surgery very quickly, and throughout his blood pressure, tissue oxygen levels and other vital signs were constantly monitored. He was kept warm by the heated table, heated incoming oxygen from the anaesthetic machine, and heated IV fluids. We breathed for him.

When I opened his abdomen, cutting from just below the point of his chest (xiphoid) to past his belly button (umbilicus), I saw a huge resolving blood clot lining the right side of his body wall. His right kidney was still swollen but looking ok, and the organs visible in the abdomen all looked good. The tear in the diaphragm was surprisingly easy to find - it was on his left side, extending almost the entire length of the muscular portion of the diaphragm, a rent of about 6cm. Flowing through this tear was the omentum, that sheet of connective tissue, fat, blood vessels and lymphatics that surrounds and protects the abdominal organs. I had to gently pull this back into the abdominal cavity, and then found that his stomach had curved round and sucked as much of itself as possible into the hole, along with the duodenum and small intestine. The intestine and stomach looked ok as they came back out into the open. Marmalade was still managing to maintain good oxygen levels at this point because the tear was still blocked with invading abdominal tissues. I took a deep breath and removed the last piece of omentum from the hole. All that was now curving round into his chest was the entire right half of his liver. I slipped a finger past this, wondering how I was to get the liver back in place (it bleeds really easily when touched, and you cannot grasp it with forceps because those just slip through the liver tissue and then it really does bleed!). My finger touched Marmalade's little beating heart and I just about jumped out of my skin. Carefully, with all the organs padded out of the way, I slipped my finger back through the tear and applied the gentlest of pressures to move the liver through the hole. I thought it would never happen. That liver was too big! How did it all get there anyway? And then with a spine-chilling gloopy movement, it slid through and that was it - just a gaping hole left and a cat heaving his chest with collapsed lungs and Caroline breathing for him. There was no time to enjoy the cold sweat and chills from getting the liver out in one piece, Marmalade needed that diaphragm closed quickly and the air taken out of his chest cavity so that his lungs could work. I placed a stay suture into the middle of the tear, which helped the handling of the heaving diaphragm quite a lot. Then padded off the liver to one side, because it really wanted to be back in its usual spot but that was in my way right now. Then I did a continuous suture pattern as quickly as I could to bring the edges of the wound together. As soon as that was done, Caroline handed me a sterile 6ml syringe and I started sucking the air out of his chest cavity as quickly as I could. The pulse oximeter was reading in the 60's at this point and Caroline was really anxious. An amazing number of 6ml draws later, but really only in about 2 minutes, the pulse oximeter was back in the high 80's and everybody was relaxing. The texts advise to place a chest drain, and it is especially important not to reinflate the lungs too rapidly because that can cause the fatal complication of reperfusion pulmonary oedema. I did not place a drain, because I felt I had achieved a satisfactory level of reinflation. My goal was now to get out as quickly as possible. I placed three or four more holding sutures into the diaphragm, checked that all blood vessels, oesophagus and bits and pieces were all where they should be, and removed the stay suture. The liver slid back into its spot, but not all the way. I checked the blood vessels were not twisted and relied on the omentum and normal abdominal healing to get everything else back into its functional place. You can only handle tissues so much. Amazingly, the whole surgery had been bloodless. Holding my breath, I checked again that I had taken all the Lap sponges out of the abdominal cavity, and started closure of the incision.

As soon as that was done, we whipped off the drapes. Caroline neutered him as I took of another 90mls of air from his chest cavity by thoracocentesis. This brought his pulse oximeter levels to 98% saturation. The isoflurane was tur
ned off, he received more IV antibiotics and dexamethasone, and was placed to recover in the snug oxygen cage as soon as he was extubated.

The worst part of his recovery was he kept trying to check the neuter site before he could co-ordinate himself.

Radiographs the next day showed that the caudal (towards the tail) part of his right lung was still completely collapsed and consolidated. There was a small amount of remnant air - pneumothorax - but Marmalade by this time was so well recovered he was way too wiggly to consider thoracocentesis. Over the next week that lung expanded fully, the pneumothorax resolved on its own and Marmalade just started getting stronger and fatter. He did get two different courses of antibiotics after surgery, and we kept the dexamethasone (steroid antiinflammatory) treatment up for the first seven days. Three weeks later his follow up radiographs showed an intact diaphragm with possible adhesions ventrally to the base of the heart, and a still inflamed right lung with some characteristic bronchial changes associated with inflammatory lung disease in the left lung.

I think Marmalade may have been kicked or taken a blow to the belly. His surgery costs were paid for by our Dabby Fund. A lot of people have donated - thank you all!