Moxie Gets Spayed

Pre-Surgery Review

I’m sitting between two of my best friends, both scary smart introverts, Ryan and Derek (I know, another Derek, what are the odds of two dudes with a name that means “The Chosen One”?). Along with a third of my fellow third-year veterinary students, we pay close attention to a bright projector screen while one of our surgery professors reviews anatomy and surgical technique. He’s tall, lanky, wears mint-green scrubs, and has salt-and-pepper hair that’s mostly pepper.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

The procedure, a cat spay, or ovariohysterectomy, is routine, but the circumstance isn't. His light and easy-going delivery clashes with the tension we all feel about the fact that we students are about to perform surgery for the first time in our lives. What’s more, I’ve committed to adopting my patient after surgery.

Having completed two-and-a-half years of mostly classroom learning, Junior Surgery is a dunk in the medical deep end that marks the beginning of our hands-on clinical training. We’ve broken into teams of three and will rotate through the roles of anesthetist, surgical assistant, and surgeon. I’m the first in my trio to cut, Derek will assist me, and Ryan will run anesthesia.

A photo flashes onto the screen of a cat’s open abdomen, organs visible. Gloved fingers grip a tiny bright pink tube of flesh attached to a transparent, paper-thin sheet of tissue that dives into a coil of other tiny bright pink tubes. Our professor points to the gripped tube and says, “This is the left horn of the uterus. We want to remove this.” He points to the coiled tubes and says, “This is the small intestine. We don’t want to remove this.”

Sweat seeps from my pores and blood rushes in my ears, my face feels hot. I glance sidelong at Derek and Ryan, and notice them glancing sidelong at me. I lean toward Ryan and whisper, “I can’t see the difference.”

His eyes are wide, “Me either, bro! What the fuck!”

The professor’s voice breaks through, “I know, I know, they’re hard to tell apart.” I relax a little. “But don’t mess it up.” He smiles big and my anxiety spikes right back up.

He continues, “The uterus has longitudinal muscles and no peristalsis.” He throws us a conspiratorial smile that says a wisecrack is coming and says, “It also has an ovary at the end.” His humor lands well; we know he’s on our side. He adopts a more sober tone and assures us, “All of you are prepared for this. You’ve gotten used to the preserved specimens, but you’ve all handled the living structures too. It just feels scarier when you’re the one responsible. You’re gonna do fine.”    

Another slide shows the gloved hand gripping the front end of the uterine horn, the dark pink shrouded ovary now visible just beyond. The whole thing now looks impossible to confuse for the small intestine. “Told ya,” he says, “No worries.”

The professor points to the leading edge of the transparent sheet of connective tissue running along the uterus. “This thickened cranial portion of the broad ligament is our suspensory ligament. You’ll have a nice, long incision today, so visualization won’t be an issue, but we want you to get comfortable tearing this thing. It sounds barbaric...well, it feels even worse...but when you can’t see what you’re cutting, it’s safer to tear it and you need to learn what it feels like. With that sucker torn, everything moves a lot easier and you’re less apt to tear something that’ll bleed.”

We wrap up the review and our flock of twenty-somethings and a few older-than-twenty-somethings shuffles over to the surgery room. I can feel the sweat accumulating under my arms and I silently curse the prohibition on under-shirts (one less thing to carry bacteria into the surgical space). As we walk, I glance around and don’t spot anyone who looks as nervous as I feel.

Derek says to me with his coastal Massachusetts accent, “Derek, you must be WICKED nervous!” His eyebrows are high and he grins widely, “I’m sure glad I’m not goin’ first.”

I smile back. “Thanks for the support, man.” I can feel sweat soaking into my scrubs under my arms. I glance around and my insecure, anxious brain sees only self assurance on the faces of my peers.

Pre-Surgery Set-Up

Our flock enters the surgery room, which is unlike any I’ve seen in person before or since in its scale. As I file into the cavernous rectangular space at the end of a long side, I pass a stainless steel scrubbing station on my right. As I turn left, long white walls on either side stretch away from me to large windows framing a set of double stainless steel swinging doors at the far end. Through the glass, I can make out steel kennels with soft bedding. Our patients wait inside with empty bellies, having been fasted overnight to avoid regurgitation while anesthetized.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

We spill into the central aisle and splinter off to five gleaming stainless steel surgical tables extending from each long wall. Ten surgical stations in one room is a LOT. Each table is lit by a powerful swing-arm overhead lamp and attended by a modular-looking anesthesia machine. The machines are a collection of canisters and tubes and valves and bags - they look somehow both antique and futuristic simultaneously. I wonder how after a hundred years of tinkering improvement, these life-saving machines still look like found object art. Stainless steel adjustable-height instrument tables round out each surgical station.

Staff and students begin the ritual of setting up and checking that the anesthesia machines are functioning properly. We plug green oxygen-supply hoses into the walls with a hiss and a metallic click. Kitties are small little creatures that lack the lung volume and power to push gas through a traditional circular rebreathing system. Instead, we attach a non-rebreathing system that directs exhaled air through a filter that traps excess CO2 and anesthetic gas. A series of pressure tests confirms our machine is good to go.

We place a v-shaped positioning trough on the table and cover it with clean towels to reduce heat transfer from the patient to the table. Atop the towel, we place a metal plate and connect its snaking wire to a cautery machine. The system works by forming an electrical connection with the patient and we use a saline-soaked pad to improve that connection (medicine learned this tidbit from its origin in making the electric chair more effective). Sometimes folks use alcohol on these pads, but that’s inadvisable with all of the sparking and oxygen nearby.

Pre-Anesthetic Exam

The Cat-Who-Will-Become-Moxie doesn’t have a name yet, just a number. She’s a petite Shorthair Russian Blue kitten, a few months old, with cuddly-soft gray fur. She reaches out at us playfully through the vertical stainless steel bars of her kennel door. She’s struggling with the tail end of a viral upper respiratory infection (URI) and her left eye is half-closed, the upper part of the cornea is gray instead of clear, and clear fluid runs down the side of her nose, leaving a light brown crust. She snuffles through a stuffy nose, but seems utterly unconcerned - she just wants to plaaaaaaay with us.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

I’m nervous taking responsibility for Moxie because Calicivirus and Herpesvirus, the most common causes of URI in cats, usually remain an intermittent lifelong nuisance. The severity and early onset permanently narrow the opening between the eyelids (palpebral fissure) in her left eye, so she develops a bit of a Sylvester Stallone look (though Sly’s face and eye droop resulted from forcep-induced nerve damage during birth). Her runny eye never improves either because the duct that normally carries tear film into the nasal passage (the nasolacrimal duct) becomes permanently blocked. Her eye clears up only partially as Inflammatory fluid in her cornea subsides. The result is a sleepy-looking half wink with a slight ghostly glow.

The remainder of Moxie’s physical exam is normal. With normal pre-anesthetic labwork and a resolving URI, Moxie is cleared for surgery. Anesthesia medications inhibit heart and respiratory function, so we reduce the overall doses needed by layering less risky medications. Protocols vary based on species, patient health status, planned procedure, and other factors. We start by pre-medicating Moxie with an injectable opiate pain medication. This has the double benefit of moderate sedation and preemptive pain control, but without affecting blood pressure. Fifteen minutes later, Moxie is dopey and pliable enough to place an IV catheter in her front leg without stress or pain. Derek and I then leave Moxie with Ryan to be anesthetized while we move on to scrub in.

Scrubbing-In

I tuck in my scrub top and tie on my surgical cap as we approach the silvery scrubbing station. The high arched faucets look like graceful gleaming goosenecks. I mention the imagery to Derek and he replies, “Alliteration, much?” I laugh and approach the station.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

From behind me, I hear Derek say, “Forgetting something?” I turn to see Derek peeling open his one-time-use sterile gown.

“Every time. At least I hadn’t sudsed up yet.” I join him and we unfurl the blue paper wrappers, careful not to touch or contaminate their contents, and leave the pre-folded gowns lying on top. We unfold sterile gloves (size 7 ½ for me) and leave them out as well.

As I tie on my surgical mask, I shoot Derek a sarcastically deferential look and he says, “There ya go. NOW you can scrub.”

I press down on the foot pedal and test the water with my fingers, then let it coat my arms down to my elbows. The start of the ritual settles my nerves. I peel open a brand new sponge pre-soaked in antimicrobial soap. The fingernail pick is no use to me - I have the high-strung habit of chewing my nails too short - so I toss it straight away. I squeeze the soft sponge under the faucet, adding water and bubbles to create a rich lather, which I spread all over my hands and forearms. I rinse this first lather to clear the larger debris and reapply.

Next, I vigorously scrub every square centimeter from my fingers to my elbows with the bristled side of the sponge for a full five minutes (try timing yourself next time you wash up). The action is carefully choreographed to assure sufficient contact time and agitation to well and truly rid every nook and cranny of all microbes and contaminants.

I turn to Derek, “At least we only have to worry about protecting our patients from us. I couldn’t handle worrying about getting something infectious from them.”

“Agreed.”

I rinse off the scrubbed lather, keeping my hands raised and making sure the water only flows away from my fingertips. Shaking the last drips from our elbows, Derek and I turn to our open gowns holding our hands aloft as if frozen in the middle of a lazy, back-handed patty-cake. Our newly clean hands can now only touch sterile objects until after surgery - a single mask adjustment, scratch of the nose, or graze of a table means an arduous re-decontamination process.

“Is ‘re-decontamination’ a word?” Derek ignores me; he’s focusing intensely on unfurling his full-length light blue paper gown without touching anything around him. He struggles tentatively and nearly flips one of his sleeves against the table at one point, but triumphs over the backwards-facing smock in the end. His grin is broad and beaming as our supervising technician fastens the Velcro neck and ties the internal waistband.

“I love watching you geniuses struggle like you’ve never gotten dressed before,” she teases. I follow suit and we both struggle through the deceivingly complex gloving procedure without our hands ever leaving the gown’s sleeves.

“Good, now dance with me,” she says.

We each dutifully hand her a tab attached to our outer waistband, spin in a circle, and grip the band while she pulls away the tab, leaving us in self-contained cocoons of sterility. We tie ourselves off and I move further into the surgery room with a stilted gait and hyper-awareness of my every movement.

I stand next to Derek as the room populates with identical stiff, light-blue-cocooned students. “My shoulders are already aching,” I say.

“So ah mine.”

“And I’m already sweating buckets.”

“Me too.”

“Are we really doing this?”

“You ah.”

Surgery Site Prep

Moxie and the other nine patients are stretched out on the tables anesthetized, prepped, and ready to go. Their delicate little bodies look vulnerable. Interconnected through the lines and canisters and tubes, through the building’s oxygen and scavenging systems, our patients and the building breathe as one. I’m humbled by the responsibility to keep my creature safe throughout an extreme invasion of her body. My stomach flutters hollowly as I walk down the center aisle with my colleagues the same way it always does when I approach a starting line, a first day of school, an exam. It says, “You’re meeting a moment that matters, and it won’t wait for you. Do well, or get the fuck out.”

Derek and I stand on opposite sides of the table and carefully affix towels to Moxie’s skin, leaving a bare rectangle in the center. We layer a large drape - with a pre-cut hole - over the top, obscuring the whole table and providing one continuous sterile surface, broken only by a narrow strip of Moxie’s bare belly.

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

Both of us gaze at the incision site. I say to Derek, “The drapes really depersonalize the whole thing.”

“No kidding.” His eyes lift to meet mine, “I’m still wicked nervous, though.”

“YOU’RE nervous? I’m shitting my pants.” I turn to Ryan, “How we doing?”

He disengages his stethoscope from his ears and loops it behind his neck with jerking movements, as if his muscles are strung too tightly. His words are rapid-fire, “What? Sorry. I’m shitting my pants here, guys. What did you say?”

Derek and I both laugh, “Nothing. Nevermind.” Ryan nods imperceptibly and turns his laser focus on the anesthesia machine. It withstands the gaze admirably - it doesn’t even melt. Ryan grabs  a dial and makes a minute adjustment.

Surgery - Incision

Derek and I arrange our instruments, count our sponges, and wait. Eventually, the supervising surgeon, scrubbed in but not touching anything, makes his way to us. “Which one of you is the surgeon? You’re both Derek, get it? No, but seriously, who’s cutting?” I raise a gloved hand. “Okay, tell me what you’re gonna do.”

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

I regurgitate the textbook, “I’m going to make a ventral median skin incision, sharply and bluntly dissect until I visualize the linea alba, tent the linea alba with Adson-Brown forceps, turn my scalpel blade upward and make a nick incision, then use the Adson-Browns to tent the linea while I extend the celiotomy with my scalpel blade.”

“Yep. Have at it.”

Executing the process takes much longer than describing it. Despite my preparation, there’s no analog for the physical and emotional sensations of performing surgery on a live patient. Moxie’s skin is tougher than it has any business being for how thin it is - I take two tentative passes with my scalpel to get all the way through. When I wimp out on the incision length, the professor admonishes me, “They heal side-to-side, not end-to-end. Give yourself room to work safely.”

Moxie has more subcutaneous fat than I expect, an irregular layer of brilliant translucent white, like moonstone cottage cheese. Deep crimson blood seeps into the area, snaking delicate rivulets in every crevice it can find. I use the blunt tip and cutting edges of my scissors to clear away the fat until I encounter a smooth surface with a subtle rainbow sheen. This is the external rectus abdominus sheath, a tough fibrous envelope containing the abdominal muscles.

My target, the linea alba, is a narrow central strip where the left and right envelopes meet. The linea alba contains no blood vessels or nerves, making it the prime entry point for most abdominal surgery. (The first veterinarian I ever worked for, when I was in eighth grade, once pointed to the linea during a spay and said, “‘Linea alba’ means ‘white line’ in Latin. It’s like God’s ‘cut on the dotted line’ for abdominal surgery.”)

I know what it looks like, I can describe it in detail, I know where is should be...and for the life of me I cannot find it now that I need it. The professor’s encouraging voice breaks through my rising panic like a rescue boat out through fog, “It’s really tiny in kittens. They have very mobile skin. Try making small lateral excursions.”

I find it, but my entry into the abdomen veers off course slightly into the muscle next to the linea. “Not to worry. Unavoidable in this case,” says the professor.

The professor moves on to supervise the next incision. Derek looks at me and says, “Damn, dude, that was great! How d’you feel?”

“Sweaty.”

Surgery - Ovariohysterectomy

We fish around and closely inspect about fourteen loops of small intestine before we get ahold of a tube with an ovary at the end of it. “We found it!” I exclaim.

Derek’s laugh is loud and honest. “It’s embarrassing how excited we ah! Let’s nevah tell anyone about this.”

“Of course. Nobody’ll ever know.”

Having found the ovary, we wait for supervision before the next key step. Looming above me, the professor says, “Okay, tell me what you’re gonna do.”

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

“I’m going to grip just caudal to the ovary and stretch the suspensory ligament, then break the ligament with a ‘strumming’ motion. Then I’m going to triple-clamp, double-ligate, and transect the ovarian artery and vein. After checking that there’s no bleeding from the ovarian vessels, I’ll replace the pedicle in the abdomen, then tear the suspensory ligament and repeat the process on the other side.”

“Yep. Go for it.”

With my right hand, I grip the tough tissue just behind the ovary and pull. When I loop my left index finger over the suspensory ligament, it’s taut as a guitar string. I ‘strum’, or at least what I figure ‘strumming’ means in this context, and as nothing continues to happen in the face of my ‘strumming’, my apprehension turns to impatience. To the professor, I say, “So...when we say ‘strum’...”

“Just add steady pressure until it gives.”

I change my technique and start pulling...harder...and harder. I add pressure until the ligament starts to bite into my hooked finger and my brain yells with rising disbelief that this CAN’t be right. Just at my maximum-cringe-point, the ligament abruptly snaps loose from its deep anchor point and Moxie starts huffing and puffing forcefully. Her heaving breaths force her intestines to follow the path of least resistance, and more of them spill out through the incision with every breath.

Despite being intellectually prepared for this benign response to a painful stimulus, the reality feels alarming, even dangerous. I’m not the only one overwhelmed, either. As I reflexively lay my hand flat over Moxie’s incision to contain the organs, Ryan immediately reaches out to adjust the anesthetic level and turns it off momentarily before realizing the mistake and turning it back on and then up. I understand the impulse - all of us are deathly afraid of killing our patient, so our instinct is to shift toward a safe zone. In surgery, however, safety often lies in moving decisively forward.

The adjusted anesthetic and Moxie’s higher breathing rate bring her back to a deeper level of anesthesia. I take a deep breath and try to collect my wits. Freed from its main tether, I can move the ovary far more freely. I can feel how this maneuver will allow a much smaller incision in my future patients. The professor says, “Good job. Perfectly done. Now you’ll never forget what that feels like. Carry on.”

With several more pauses for supervision, I proceed to clamp and tie off the ovary’s blood supply, then cut it free. I check to make sure my ligatures are solid, see no bleeding from the cut vessels, and gently replace the ovarian pedicle back in the abdomen. Next, I tear the thin, transparent sheet of connective tissue attached to the uterine horn until I reach the uterine body. There, I pick up and follow the other uterine horn and repeat the whole process, which goes  goes more smoothly now that we’ve been through it once. Finally, I tie off and cut through the uterine body, and then lay the whole y-shaped uterus on the instrument table.

Surgery - Closure

While Derek and I count our sponges and instruments to make sure none of them accidentally ended up in Moxie’s abdomen, I say, “Tearing that ligament felt barbaric.”

Derek, being more interested in Large Animal medicine, says, “It looked like it. I’m glad we don’t spay horses.”

The professor circles back around and says to me, “Okay. Tell me what you’re gonna do.”

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

“I’m going to close the linea alba in a simple interrupted pattern using absorbable suture. Then I’ll close the subcuticular layer in a simple continuous pattern. Then I’ll close the skin in a continuous intradermal closure.”

“What’s the holding layer for the linea?”

“The external rectus abdominus sheath.”

“Great. Go for it.”

Being right-handed, I close from right to left. The synthetic suture is dyed dark blue for visibility and extends stiffly for about 18 inches from a pre-attached, curved needle. It looks not unlike a hair from a cheap blue wig. Using a specialized set of forceps that look like very delicate long-handled pliers, I drive the needle through the tough outer layer of the abdominal muscle sheath on both sides of the incision, draw the edges together, tie a stack of six knots, and trim the ends.

My progress is halting and maddeningly slow as I meticulously place twenty to thirty more such interrupted sutures with appropriate spacing, bite depth, distance from the edge, tension, and knot security. A continuous pattern, with knots only at the ends of the incision rather than between each pass of the needle, is faster, but then one knot failure could lead the entire incision to open back up. The trade-off today is that although our inexperience hands move slowly and our patients spend more time under anesthesia, many knots would have to fail for a significant problem to develop.

I take far less time closing the next two layers by using continuous patterns. I struggle with the technique of tying buried knots on the skin layer, but eventually prevail. All told, closure takes longer than the spay portion of the surgery, and my final surgery time from incision to closure (skin-to-skin) is around two-and-a-half hours. Later in my career, I’ll perform the same procedure in  fifteen to twenty minutes, sometimes ten or twenty a day.

Recovery

Derek and I gaze at our hard-won prize.

Derek says to me, “It’s embarrassing that it took us this long to remove that tiny little thing.”

“Don’t worry,” I assure him, “Nobody’ll ever know."

Illustration by Angela Mancini, all rights reserved by DerekTheVet.com

I step away from the surgery table and peel off my gloves and slingshot them into the kick bucket. As I pull off my paper gown, I feel a cold rush as the air hits my sweaty scrubs. The tunnel vision of surgery dissipates as I remove my cap and mask and take in the context of the room. Today’s surgeons and assistant surgeons emerge from their own sterile cocoons smiling broadly with flushed faces and hat-hair. The room is suffused by a gentle air of pride and camaraderie, some high-fives are exchanged, but celebration is curtailed while today’s anesthetists tend to our recovering patients.

I take a moment to soak in the sensations. My shoulders and neck ache as I stretch and breathe deeply. Sitting is a huge relief. My scrubs are soaked through with sweat and I long for a shower. I’m struck by waves of mental exhaustion, my first taste of how draining the intense focus required for surgery can be. Sitting on a step-stool with my head leaned back against the wall, I’m terrified that I made some critical, undetected mistake. I remind myself about the close supervision, but the responsibility of the role hangs on me like a heavy coat.

After a few minutes, Moxie wakes up enough to swallow and we remove her breathing tube before she can chew it in half. Her recovery is smooth and she eventually reaches a sluggish consciousness and looks up at me with her good eye, her squinty one only open a sliver. We confirm that her pain is well-managed and monitor her until she’s alert enough to be left alone. A bit later, we reintroduce food and she eats hungrily.

Home

That night, I take her home and set the carrier in the middle of the living room of my one-bedroom basement apartment. She marches out of the carrier and straight over to the litterbox I’ve set up in the bathroom. After christening the latrine, she explores confidently before choosing a spot on the arm of the sofa and falling asleep.

Later, when I crawl into bed, she jumps up and I decide it’s okay as long as she stays on the comforter. Over the next hour, she demonstrates that she will pleasantly, but invariably, do as she damn well pleases. A cat with her force of character can only be called “Moxie.”