Oh 7

The Veterinary Record, September 2, 2006
THE ovariohysterectomy of cats is one of the most common
surgical procedures in small animal practice. It is commonly
carried out either through a midline coeliotomy or through
a flank laparotomy. In the UK, the flank approach is believed
to be preferred, whereas the midline approach is said to
be preferred in the USA. There have been two small stud-
ies comparing these two surgical approaches (Hoque 1991,
Ghanawat and Mantri 1996), but to the authors’ knowledge
no substantial prospective studies have been made to com-
pare them.
At the University of BristolVeterinary School, a spay-neu-
ter clinic is a key part of the teaching of soft tissue surgery for
final-year veterinary students, who perform the operations
under the direct supervision of veterinary surgeons, as per-
mitted by the Veterinary Surgeons Act. This study was in two
parts; first a survey of UK veterinary practitioners was made
to establish their preferred approach to the ovariohysterec-
tomy of cats, and secondly, a prospective study was carried
out to test the hypothesis that there would be no significant
differences between the two approaches, in terms, for exam-
ple, of the duration of surgery or the incidence of surgical
complications, when the operations were performed by vet-
erinary students being taught surgery.
MATERIALS AND METHODS
Survey of UK veterinary practitioners
A questionnaire was sent to 462 veterinary practices in the UK,
407 via a commercial mailing list and 55 via final year student
extramural study placements. The practitioners were asked
to give their preferred approach to the ovariohysterectomy
of cats (either flank or midline), and their preferred ligature
materials for tying off the ovarian and cervical pedicles.
Clinical study
Sixty-six cats from local animal welfare organisations under-
went ovariohysterectomy before being rehomed. They were
more than six months and less than 10 years of age, healthy
(American School of Anaesthesiologists grade 1), and were
not in oestrus, lactating or pregnant.
They were randomly assigned to either a flank or midline
surgical approach by blocked randomisation.The anaesthetic
protocol was identical for all of them. Acepromezine maleate
(ACP Injection; Novartis Animal Health) at 0·1 mg/kg was
given as a preanaesthetic sedative by intramuscular injection;
30 minutes later anaesthesia was induced with intravenous
thiopental sodium (Rhone-Merieaux) to effect and main-
tained with halothane (Rhodia Organique Fine) in 100 per
cent oxygen via an Ayer’s T-piece with Jackson-Rees modifi-
cation, with the cats breathing spontaneously. Carprofen (4
mg/kg) (Rimadyl; Pfizer) was given subcutaneously immedi-
ately after induction to provide analgesia, and a single dose
of clavulanate-potentiated amoxicillin (Synulox; Pfizer) was
given subcutantously to provide antimicrobial prophylaxis.
Final year undergraduate veterinary students were allo-
cated to perform the surgery under the direct and continu-
ous supervision of faculty members or clinical training
scholars (residents). The students were allocated to each
case before the approach was selected, to eliminate any bias.
Before performing the surgery, the students were directed
to read an account of the standardised method to be used
for either a midline or a flank approach as appropriate. The
number of operations already performed by the student as
primary surgeon by the flank and midline approaches was
ascertained.
The cats were prepared routinely for aseptic surgery by
the relevant approach, and the urinary bladder was palpated
and emptied manually if necessary. The clinicians supervis-
ing the surgery allowed the students to proceed unless they
requested assistance, or they needed to intervene to prevent
errors. Verbal encouragement and reassurance was provided
throughout the procedure. The technique for the surgery was
standardised as far as possible and was as follows.
Flank approach The cat was placed in right lateral recum-
bency and its legs were extended caudally with ties. The
position for the incision was identified by visualising an
equilateral triangle with vertices at the greater trochanter,
the wing of the ilium and the centre point of the incision
(Feathers 1974); a sterile wire template 2·5 cm in length
was used to standardise the length of the incision. The skin,
subcutaneous fat, external aponeurosis, internal and trans-
verse abdominal obliques and peritoneum were incised in
a dorsal to ventral direction to enter the peritoneal cavity
(time 1). In some cases, owing to difficulty in identifying
or exteriorising the genital tract, it was necessary to extend
the skin incision. The uterus was identified (time 2) and
exteriorised. A window was made in the broad ligament/
mesovarium proximal to the ovary and the ovarian pedicle
was double clamped with Halstead ‘mosquito’ haemostats.
The pedicle was ligated immediately below the haemostats
with 2 metric braided lactomer (Polysorb; US Surgical). The
pedicle was sectioned between the clamps and the stump
Comparison of flank and midline approaches
to the ovariohysterectomy of cats
R. J. Coe, N. J. Grint, M. S. Tivers, A. Hotston Moore, P. E. Holt
In a survey of UK veterinary practitioners, 96 per cent indicated that they performed ovariohysterectomy
on cats via flank laparatomy rather than a midline coeliotomy. At a veterinary teaching hospital 32 cats
were spayed by the midline approach and 34 by the flank approach, by undergraduate students under the
continuous supervision of a veterinary surgeon. The duration of each part of the procedures was recorded
and information was obtained from the students, the supervisors and the owners of the cats by means
of questionnaires. The total duration of the surgery and the students’ assessment of the difficulty of the
surgery were not significantly different between the two groups. The time taken from the skin incision
to entering the peritoneum was significantly longer with the flank approach, but finding the uterus took
significantly longer with the midline approach. There was a high incidence of wound complications, in the
form of swelling, redness or discharges, but the only statistically significant difference between the groups
was a greater incidence of discharges in the cats spayed via the flank (five cases) than in the cats spayed via
the midline (one case).
Veterinary Record (2006)
159, 309-313
R. J. Coe, MA, VetMB,
CertSAS, MRCVS,
N. J. Grint, BVSc, CertVA,
MRCVS,
M. S. Tivers, BVSc,
MRCVS,
A. Hotston Moore, MA,
VetMB, CertSAC, CertVR,
CertSAS, MRCVS,
P. E. Holt, BVMS, PhD,
ILTM, DECVS CBiol,
FIBiol, FRCVS,
University of Bristol,
Department of Clinical
Veterinary Science,
Langford House,
Langford, Bristol
BS40 5DU
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was grasped with rat-toothed forceps for inspection after
the removal of the haemostat; after establishing that there
was no haemorrhage the pedicle was released. The procedure
was repeated for the other pedicle. The uterine body was
exteriorised and an encircling ligature of 2 metric braided
lactomer was placed cranial to the cervix without clamping.
After the placement of this ligature the uterine body was
triple clamped and a further ligature was tied into the crush
of the lowest clamp. The uterine body was sectioned between
the second and third clamps and the cervical stump was
inspected for haemorrhage (time 3). The internal and exter-
nal muscle layers were closed together with 2 metric braided
lactomer in a simple continuous pattern. The subcutaneous
fat was also closed with 2 metric braided lactomer in a sim-
ple continuous pattern. A further subcuticular/intradermal
continuous suture of 2 metric poliglecaprone (Monocryl;
Ethicon) was used to appose the skin edges, and no skin
sutures were inserted.
Midline approach The cat was placed in dorsal recumbency.
Using the 2·5 cm wire template to define the length of the
incision, the skin and subcutaneous fat were incised in the
midline midway between the umbilicus and the pubis,expos-
ing the rectus abdominis muscles and linea alba. A midline
or slightly paramedian incision was made through the linea
alba or rectus abdominis muscles and parietal peritoneum to
enter the peritoneal cavity (time 1).
The procedure was then identical to that described for
the flank approach. The uterus was identified (time 2) by
repelling the intestine cranially and the bladder caudally and
grasped with atraumatic forceps. The incision was extended
if necessary. On completion of the ovariohysterectomy (time
3) the incision in the abdominal wall was closed with 2 metric
braided lactomer in a simple continuous pattern. The sub-
cutaneous fat was closed with 2 metric braided lactomer in a
simple continuous pattern. A subcuticular/intradermal con-
tinuous suture of 2 metric poliglecaprone was used to appose
the skin edges and no skin sutures were inserted.
Students’ response After the surgery the cats were moni-
tored for 18 to 24 hours before being discharged from the
hospital. The tenderness of the wound and the level of seda-
tion of the cat were assessed regularly by a veterinary anaes-
thetist, and additional analgesia was provided if required. No
further antimicrobial medication was administered.
After the surgery the students were asked to complete a
questionnaire. They were asked to indicate by means of 100
mm visual analogue scales (VAS) (with very easy and very
difficult, or very confident and not confident at all being
indicated by 0 and 100 respectively), how difficult they felt
the surgery had been, how difficult it had been to identify
the uterus, how difficult it had been to exteriorise and ligate
the ovaries, and how confident they would be to repeat the
procedure unassisted.
During the surgery, the times in seconds from the first
incision to each of the times referred to, were recorded and
the times to complete the various stages of the procedure
were designated I to P, P to G, G to S, and S to C (Fig 1), indi-
cating respectively the time from the first incision to entering
the peritoneal cavity, the time from entering the peritoneal
cavity to exteriorising the genital tract, the time from exte-
riorising the genital tract to removing it completely, and the
time from the removal of the genital tract to the completion
of the operation. The length of the incision at the end of the
surgery was also recorded.
Surgeons’ response The supervising surgeon also com-
pleted a questionnaire; 100 mm VAS scales (with no interven-
tion and continuous help, and very good and very poor, that
is, higher scores indicating poorer performance, indicated by
0 and 100) were used to indicate the level of intervention
during the procedure, and the student’s level of proficiency.
Stages during the procedure requiring particular interven-
tion, and any complications were also recorded.
Owners’ responses The cats were discharged the morning
after the surgery. The owners were given a questionnaire and
asked to complete and return it seven days later. They were
asked to record any wound complications (discharge, exces-
sive licking, swelling or breakdown) and grade them as mild
or severe. They were also asked to indicate on 100 mm VAS
scales (with no signs of pain and extreme discomfort, and
very satisfied and very dissatisfied, indicated by 0 and 100)
the level of discomfort they felt their cat had experienced,and
their degree of satisfaction with the appearance of the wound
seven days after the surgery. They were also asked to indicate
whether, given a free choice, they would prefer their cat to be
spayed by the flank or midline approach; the questionnaire
contained basic information, in layman’s terms, of what was
involved in the two approaches.
The results were analysed by using SPSS 12.02. The data
were plotted as histograms to check for normality. For the
purposes of correlation, the data for the total number of
spays performed before, and the total time taken to perform
the ovariohysterectomy were transformed logarithmically
to reduce their skewedness. Parametric data were com-
pared by using student’s t test. Non-parametric data were
compared by the Mann-Whitney U-test (exact two-tailed).
Spearman’s rank coefficient was used to assess correlations.
Categorical frequency data were tested by the chi-squared
test. Significance was set at the 5 per cent level.
RESULTS
Survey of UK veterinary practitioners
Of the 462 questionnaires, 183 were returned, a response rate
of 39·6 per cent.
In answer to the question about the approach used, two
responses were unclear but 174 of the 181 other respondents
(96·1 per cent) indicated that they used the flank approach,
and the other seven that they used the midline approach.
In answer to the question about ligature material four
responses were unclear; of the other 179, seven (3·9 per cent)
indicated that they used no ligature material, 159 (88·8 per
cent) used chromic catgut, 12 (6·7 per cent) used polyglactin
910 (Vicryl; Ethicon) and one used polyglycolic acid (Dexon;
US Surgical).
Clinical study
Thirty-four of the 66 cats underwent ovariohysterectomy by
the flank approach, and 32 by the midline approach.
The mean (sd) final length of the midline incisions was
3·1 (0·6) cm and the mean final length of the flank incisions
was 2·6 (0·2) cm, and significantly shorter (P=0·001).
Start of surgery Open peritoneum Find genital tract
Start abdominal
closure
End of surgery
I – P P – G G – S S – C
FIG 1: Stages of the ovariohysterectomy procedure whose durations were recorded. I-P
Time from first incision to entry into the peritoneal cavity, P-G Time from entry into the
peritoneal cavity to exteriorising genital tract, G-S Time from exteriorising genital tract to
completion of removal of genital tract, S-C Time from completion of removal of genital
tract to completion of surgery

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Students’ responses Data from all 66 of the procedures
were available; eight of the 66 students had had experience
of both the flank and midline approaches, 37 had experience
only of the flank approach, five had experience only of the
midline approach, and 16 had had no previous experience
of either. Of the 34 students who used the flank approach
six had had experience of both approaches, 17 had used only
the flank approach, two had used only the midline approach,
and nine had had no previous experience of either. Of the
32 students who used the midline approach, two had had
experience of both approaches, 20 had used only the flank
approach, three had used only the midline approach, and
seven had had no previous experience of either. In general,
the groups of students appeared to be evenly matched in
terms of their previous experience.
The median number (range) of cats spayed by all the stu-
dents previously was 2 (0 to 50); for the students who used
the midline approach the median was 2 (0 to 20) and for
those who used the flank approach it was 3·5 (0 to 50). The
median numbers of cats spayed previously by the midline
approach were 0 (0 to 1) by the students who used the mid-
line approach and 0 (0 to 40) by the students who used the
flank approach. The median numbers of cats spayed previ-
ously by the flank approach were 1·5 (0 to 20) by students
who used the midline approach and 2 (0 to 20) by students
who used the flank approach.
The mean (sd) VAS response to the question ‘How dif-
ficult did you find the surgery?’ (0 Very easy, 100 Very dif-
ficult) was 41·8 (19·7) for the midline approach and 42·0
(18·1) for the flank approach. The mean response to the
question ‘How difficult did you find it to locate the genital
tract?’(0 Very easy, 100 Very difficult) was 48·0 (26·7) for the
midline approach and 38·0 (28·1) for the flank approach.
The mean response to the question ‘How difficult did you
find it to exteriorise and ligate the ovaries?’ (0 Very easy, 100
Very difficult) was 24·2 (17·1) for the midline approach and
33·4 (21·7) for the flank approach. The mean response to
the question ‘How confident would you feel to perform the
approach again, unassisted?’(0 Very confident, 100 Not con-
fident at all) was 31·8 (22·0) for the midline approach and
36·6 (22·7) for the flank approach. There were no significant
differences between the responses of the students using the
different approaches.
To assess whether students with more experience of spay-
ing cats felt more confident than less experienced colleagues,
the ‘confidence’ scores were correlated with the numbers of
cats they had spayed. There was no significant correlation.
Surgeons’ responses Data were available from all 32 of the
midline approaches and from 33 of the flank approaches.
The mean (sd) VAS score for the degree of intervention
(0 No intervention, 100 Continuous help) was 33·7 (19·3) for
the midline approach and 30·9 (21·2) for the flank approach.
The mean score for the students’ proficiency (0 Very good,
100 Very poor) was 36·5 (18·4) for the midline approach and
36·3 (22·3) for the flank approach; there were no significant
differences between the groups.
The supervising surgeon commented on a particular
stage of the procedure that required intervention in 23 of
the 32 midline procedures and 20 of the 33 flank procedures.
For the midline procedure the stages requiring intervention
were finding the uterus (14), removing the genital tract (6),
and closure (5). For the flank procedure the stages requiring
intervention were closure (11),removing the genital tract (4),
the surgical approach (3), and finding the uterus (2).
Intraoperative complications were recorded in two of the
midline procedures, and four of the flank procedures; in the
midline procedures the complications were that an ovarian
ligature came off and had to be religated, and that a ligature
cut through the uterine body. In two of the flank procedures
an ovarian ligature came off without gross haemorrhage,
in one both ovarian ligatures came off, again without gross
haemorrhage, and in one the uterus was incised inadvert-
ently.
All 66 cats recovered from the surgery uneventfully and
no evidence of hypovolaemia or haemorrhage was detected
postoperatively in any of them.
Duration of surgery There was no significant difference
between the total times taken to complete the ovariohyster-
ectomy by the two approaches; they were 2627 (660) seconds
for the midline approach and 2464 (732) seconds for the
flank approach.
The mean (sd) time from cutting the skin to entering
the peritoneal cavity was significantly shorter (P=0·03) for
the midline approach than for the flank approach (182[98]
v 229[111] seconds). The mean time from entering the
peritoneum to finding the uterus was significantly shorter
(P=0·007) for the flank approach than for the midline
approach (134[98] v 222[150] seconds), but there were no
significant differences between the groups for the other parts
of the procedure (Table 1).
There were significant positive correlations between
the scores for the extent of the surgeons’ intervention and
the scores for the students’ proficiency (r=0·716, P<0·01),
between the total duration of the surgery and the extent of
the surgeons’ intervention (r=0·474, P<0·01), and between
the total duration of the surgery and the scores for the stu-
dents’ proficiency (r=0·494, P<0·01).
Owners’ responses Questionnaires were returned by 24
of the owners whose cats had been spayed by the midline
approach and by 17 of those whose cats had been spayed by
the flank approach giving a response rate of 62·1 per cent.
Problems with the surgical wound were reported in 16 of
the cats (39 per cent); seven had a single problem reported,
seven had two problems, one had three problems, and one
cat had all four problems (Table 2). There was a significantly
higher incidence of wound discharge in the cats spayed
by the flank approach (P=0·04). The three cats reported
Part of surgery Midline approach Flank approach P
I-P 181 (98) 229 (111) 0·03
P-G 222 (150) 134 (98) 0·007
G-S 934 (300) 889 (226) 0·68
S-C 1290 (390) 1212 (557) 0·19
Total time 2627 (660) 2464 (732)
I-P Time from first incision to entry into the peritoneal cavity,
P-G Time from entry into the peritoneal cavity to exteriorising the
genital tract, G-S Time from exteriorising the genital tract to
complete removal of the tract, S-C Time from removal of the
genital tract to completion of surgery
TABLE 1: Mean (sd) times in seconds required to complete
different parts of the surgical procedure to perform
ovariohysterectomy on 34 cats by a flank approach and 32 cats
by a midline approach
Problem reported None Mild Severe
M F M F M F
Discharge 23 12 1 5 0 0
Excessive licking 21 15 3 2 0 0
Swelling 16 12 5 5 3 0
Wound breakdown 22 15 2 2 0 0
M Midline approach, F Flank approach
TABLE 2: Wound complications as assessed by the owners of 24
of the cats spayed by the midline approach and 17 spayed by
the flank approach, seven days after the surgery

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to have severe swelling had all been spayed by the midline
approach.
The mean VAS scores in response to the question ‘How
much discomfort do you feel your cat experienced after the
operation?’ (0 No sign of pain, 100 Extreme pain) were 10·7
(13·0) for the midline approach, and 9·9 (7·2) for the flank
approach. The mean scores in response to the question‘How
satisfied were you with the appearance of the wound one
week after surgery?’ (0 Very satisfied, 100 Very dissatisfied)
were 15·2 (23·4) for the midline approach and 12·1 (13·4)
for the flank approach. There was no significant difference
between the two groups.
The owners were asked whether they would prefer to
have their cats spayed by the midline or flank approach
in the future; 11 of the 41 (26·8 per cent) said they would
prefer a midline approach, nine (22·0 per cent) preferred a
flank approach, and 21 (51·2 per cent) had no preference. Of
the 20 owners who expressed a preference, 16 preferred the
approach that had been used.
DISCUSSION
Although there is no standard surgical approach to the
ovariohysterectomy of cats, in the USA the midline approach
predominates. Two USA-based veterinary texts suggest that
the flank approach is least preferred (Fingland 1998, Stone
2003) and a third mentions it only in passing (Hedlund
2002). However, McGrath and others (2004) advocated the
flank approach for neutering small animals in the USA. In
the UK the flank approach has been the traditional method
for many years (Hickman and Walker 1980), and the survey
of veterinary practices in the UK showed that nearly all the
vets use the flank approach. In the USA, Krzaczynski (1974)
has also advocated the flank approach, suggesting that its
advantages include the avoidance of evisceration, even when
dehiscence occurs, less surgical trauma, and shorter surgical
time.
The surgical texts (Fingland 1998, Hedlund 2002, Stone
2003) suggest that the flank approach has several potential
complications, including the possibility that the entire uter-
ine body may be difficult to remove, a dropped ovarian pedi-
cle may be difficult to recover, and that it may be difficult to
expose the opposite ovary and uterine bifurcation.
Ghanawat and Mantri (1996) observed that exterioris-
ing the opposite ovary and uterine horn was difficult from
the flank approach, although they did not explain how they
assessed the ‘difficulty’ experienced.
Another complication of the flank approach that has been
recorded is the discoloration or darkening of oriental cats’fur
when it regrows after clipping (Gorelick 1974).
The results of this study show that despite the students’
greater previous experience with the flank approach, there
was no difference in how difficult they found the flank or
midline approaches, and they felt equally confident to per-
form either in the future. However, they did appear to have
more difficulty in finding the uterus via the (to them) less
familiar midline approach.
There was no difference between the total duration of the
surgery required for the two approaches (Table 1). However,
there were significant differences between the times required
for some stages of the procedures. The time taken from cut-
ting the skin to entering the peritoneal cavity was longer
for the flank approach, probably owing to the greater com-
plexity of identifying the subcutaneous fat, and external and
internal oblique muscles and peritoneum, compared with
identifying the linea alba. The time taken from entering the
peritoneum to finding the uterus was significantly longer
with the midline approach. The supervising surgeons also
reported that the students more often needed help to find
the uterus when using the midline approach. The final inci-
sion was significantly longer after a midline approach than
after a flank approach, probably owing to the need to extend
the incision in order to identify the uterus. It is not clear
whether the difficulty in finding the uterus was due to the
students having had less experience of the midline approach,
or to this approach being genuinely more difficult. Once the
genital tract had been identified, the times taken to finish the
operation by the two approaches were not significantly dif-
ferent. The students’ VAS scores for difficulty in exteriorising
and ligating the ovaries were higher for the flank approach,
but the difference was not significant.Although the incisions
were longer after a midline approach, the time spent sutur-
ing was not significantly longer, probably because simple
continuous suture patterns were used. There was no clear
evidence that one of the approaches was easier or quicker
than the other.
In a study by Freeman and others (1987), an initial mid-
line incision 6 cm in length was used in a similar teaching
exercise. In this study, the procedure began with a standard-
ised incision 2·5 cm in length for both approaches, and it
was extended if necessary. In the flank approach the initial
incision seldom needed to be extended, but it was generally
too small for the students using the midline approach to find
the uterus. If a longer initial incision had been used for the
midline approach, the total time required for the procedure
might have been reduced.
The VAS scores for the extent of intervention by the sur-
geons were highly correlated with the scores for the students’
proficiency and these were both highly correlated with the
duration of the surgery,suggesting that (bearing in mind that
higher scores indicated poorer performances) the supervising
surgeons may have given particular weight to the speed with
which the students performed the surgery and associated that
with their level of competence. VAS scales have been shown to
be a valid and repeatable way of assessing subjective variables
(McCormack and others 1998); their use was explained to all
the participants in the study, but it is the authors’ impression
that they were better understood by the staff and students
than by the owners of the animals.
Sixteen of the 41 responding owners (39 per cent) reported
some problem with the wound; the wounds were assessed by
the owners and not by a veterinary surgeon.However,the cri-
teria used to assess the problems were descriptive and visual,
including excessive licking and mild swelling as wound com-
plications. It is recognised that surgery performed by inexpe-
rienced surgeons results in a higher rate of wound infections,
probably as a result of rougher tissue handling and longer
surgical times (Vasseur and others 1988). Despite the high
incidence of problems none of the cats’wounds required vet-
erinary intervention. Freeman and others (1987) and Muir
and others (1993), reported that the postoperative wound
complication rates assessed by a veterinarian after a midline
approach for the ovariohysterectomy of similar groups of
cats were 30 of 64 (47 per cent) and 20 of 25 (80 per cent)
respectively.
In this study, a discharge from the wound was reported
significantly more often after a flank approach. A discharge
from a surgical wound may be a result of seroma, bacterial
infection or haemorrhage.The higher incidence of a discharge
after a flank approach may have been due to the greater thick-
ness of fat and muscle incised during this approach; however,
the greater visibility of the flank site would probably have
increased the likelihood of a discharge being observed by the
owner. The owners’ perceptions of their cats’ postoperative
discomfort, and their satisfaction with the appearance of
the wound, were not significantly different between the cats
spayed by the two approaches.
The students took longer to enter the peritoneal cavity
by the flank approach but finding the uterus took longer by

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the midline approach, and the midline approach required a
longer incision than the flank approach. However, there were
no significant differences in many other aspects of the pro-
cedures and either approach may be strongly supported or
rejected as inappropriate by different surgeons. The results
suggest that neither approach has any particular advantage
over the other.However,Grint and others (2006) and Burrow
and others (2006) have shown that the mean postoperative
wound tenderness score was significantly greater in the cats
that were spayed by the flank approach.
The operations were carried out by final-year veteri-
nary undergraduates under the continuous supervision
of a veterinarian, and the findings may not be directly rel-
evant to experienced practitioners. The difficulties the stu-
dents experienced with entering the peritoneal cavity by the
flank approach, and with finding the uterus by the midline
approach are likely to diminish with experience. These parts
of the procedure appear to be the most difficult for the inex-
perienced surgeon to master. However, in a teaching environ-
ment, there is no reason to reject either the midline or flank
approach on the grounds of the duration of the surgery, the
difficulties experienced by the students, or the incidence of
postoperative complications.
The authors consider that the midline approach is prefer-
able, predominantly because the uterus sometimes cannot
be identified from the flank approach, and it is difficult to
be certain whether this is a technical problem or the cat has
already been neutered, without exploring from a midline
approach. Certain rare congenital abnormalities, such as
uterus unicornis, may also be difficult to identify and/or deal
with from the flank approach.With the flank approach, if the
ovarian or cervical pedicles are lost before they are ligated,
they may be difficult to recover. Seven of the 179 practition-
ers in the survey were content to leave these pedicles unli-
gated, a procedure which has been advocated by Hickman
and Walker (1980). In this study the ovarian ligature came off
four ovarian pedicles in three of the cats, none of which suf-
fered haemorrhage severe enough to be detectable clinically,
and they all recovered uneventfully. Nevertheless, the authors
consider that the pedicles should be ligated with synthetic
absorbable material.
One of the reasons for advocating the flank approach his-
torically was the reduced risk of evisceration if dehiscence
occurred (Krzaczynski 1974). Modern suture materials and
improved surgical technique (particularly an understand-
ing of the importance of the rectus abdominis fascia as the
strength-holding layer in abdominal closure) have substan-
tially reduced the risk of dehiscence. A larger incision was
required when using the midline approach, but it did not
adversely affect the total duration of the surgery, the healing
of the wound, the comfort of the cat, or the satisfaction of
the owner.
ACKNOWLEDGEMENTS
The authors thank the staff and students at the University of
Bristol Veterinary Teaching Hospital for their assistance in
caring for the cats in this study. Thanks are also due to Dr T.
Knowles for statistical assistance.
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doi: 10.1136/vr.159.10.309
2006 159: 309-313Veterinary Record
R. J. Coe, N. J. Grint, M. S. Tivers, et al.
cats
approaches to the ovariohysterectomy of
Comparison of flank and midline
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