R a b b i t S o f t Ti s s u e Su r g e r y

Zoltan Szabo, Dr med vet, DABVP(ECM), GpCert(ExAP), MRCVSa,*,

Katriona Bradley, BVMS, MRCVSa, Alane Kosanovich Cahalane, DVM, MA, DACVS-SA
b

KEYWORDS
 Rabbit  Surgery  Soft tissue  Gastrointestinal  Liver  Neutering  Kidney
 Thymoma

KEY POINTS
 Rabbit surgery is generally considered more challenging than dog or cat surgery due to
the physiology and anesthetic risks of the species and because postoperative complica-
tions in rabbits are more common.
 Abdominal explorations are performed to treat or diagnose different problems within the
abdominal cavity.
 The most common indication for gastrointestinal (GI) surgery is ileus due to foreign objects
or masses; gastrotomy, enterotomy, intestinal biopsy, and intestinal resection are
performed commonly.
 Surgery of the urinary tract is usually necessary due to urolithiasis or neoplasm. Nephrot-
omy, pyelolithotomy, nephrectomy, uretronephrectomy, ureterotomy, cystotomy, cystec-
tomy, and urethrotomy are discussed.
 Ovariohysterectomy, ovariectomy, and orchidectomy are the most common surgical ster-
ilization techniques in rabbits.

INTRODUCTION AND PRINCIPLES

Parallel to the increasing popularity of rabbits as pets, owners’ demands for state-of-
the-art surgical treatments are similarly increasing.1 Rabbit surgery has some addi-
tional challenges compared with dog and cat surgery, due to the specific physiology
and anatomy of rabbits. The anesthetic risk of rabbits is higher than that of dogs and
cats.2 The lack of knowledge and experience with the species on the part of owners
can also lead to unrealistic expectations and complications. Some clinical signs,
like anorexia, are mild in dogs but can indicate a potential life-threatening problem
in rabbits. Common diseases, like abscesses or intestinal obstruction, can be straight-
forward in dogs and cats, but the prognosis is usually worse in rabbits. Postoperative

The authors have nothing to disclose.

a
Tai Wai Small Animal and Exotic Hospital, 75 Chik Shun Street, Tai Wai, Shatin, New Terri-
tories, Hong Kong, China; b VSH Hong Kong, 165 Wan Chai Road, Wan Chai, Hong Kong, China
* Corresponding author.
E-mail address: drzoltan@icloud.com

Vet Clin Exot Anim 19 (2016) 159–188

http://dx.doi.org/10.1016/j.cvex.2015.08.007 vetexotic.theclinics.com
1094-9194/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
160 Szabo et al

complications, like adhesion formation, ileus, and anorexia, are also more common in
rabbits.1

Presurgical Considerations
Prior to any surgery or anesthesia, each patient should be examined thoroughly. Uri-
nalysis and blood analysis are recommended.3–5 The coagulation status of patients
should be assessed if significant bleeding is expected during surgery, especially in
patients with liver disease or anemia. The blood tests are important because, in the
authors’ experience, subclinical azotemia and anemia are common in rabbits. Abdom-
inal and thoracic radiographs are recommended, especially in geriatric rabbits
(>6 years), because subclinical thoracic masses, kidney stones, or other abnormalities
can be frequently diagnosed.6
Stabilization of a sick rabbit prior to surgery is essential. Rabbits do not need to be
fasted, because they cannot vomit. Therefore, induction of anesthesia does not carry
the same risk of aspiration as in dogs or cats. Rabbits are prone to GI stasis, and,
therefore, should be syringe-fed if anorexic prior to and after surgery.7 Monitoring
and correcting body temperatures are important because hypothermia is common
in debilitated rabbits and rabbits cannot pant or sweat effectively and are, therefore,
prone to hyperthermia. Fluid therapy should be initiated prior to surgery. Intravenous
(IV) catheters can be placed into the marginal ear vein or into the cephalic or saphe-
nous veins. If IV catheter placement is not possible, fluids can be administered subcu-
taneously or intraosseusly.8 Perioperative antibiotic therapy for routine, sterile
surgeries (eg, neutering and skin mass removals) is not necessary.9

Analgesia and Anesthesia

Detailed discussion of sedation, analgesia, and anesthesia of rabbits is beyond the
scope of this article, but they are discussed in other articles.10–12 Because of the frag-
ile nature of rabbits, sedation prior to any stressful intervention is important. In the peri-
operative period, multimodal anesthesia, using a combination of systemic and local
anesthetic drugs that target different steps of the body’s pain transmission pathway,
is essential. Gas anesthesia delivered via tight-fitting facemasks, laryngeal masks,
supraglottic airway devices, or endotracheal tubes is the preferred method to maintain
anesthesia in rabbits.13–15 During the surgery, the physiologic parameters (heart rate,
respiratory rate, oxygen saturation, body temperature, blood pressure, and carbon-
dioxide concentration in the expiratory gases) should be monitored and maintained.

Surgical Principles
The skin is aseptically prepared prior to surgery. The skin is thin and the fur is dense;
therefore, clipping should be performed carefully to prevent skin damage. Gentle and
atraumatic skin handling is important to reduce postsurgical pain and self-inflicted
wound trauma.16 Alcohol-based disinfectant should be used sparingly to reduce
heat loss.17 Because of the elasticity of rabbit skin, the skin incision can be much
shorter compared with the incision through the abdominal muscle during abdominal
surgeries. The organs should be handled gently and examined in situ without unnec-
essary manipulation. Regular lavage with sterile saline as well as the use of moistened
gauze squares helps prevent drying of the abdominal organ surface of the organs.
Wound infection is usually due to self-inflicted wound trauma. It can be prevented
with gentle preparation of the surgical site, atraumatic tissue handling, wound closure
by apposing edges correctly and with no tension, minimally reactive suture materials,
and perioperative local anesthesia.17
 Rabbit Soft Tissue Surgery 161

Postoperative Considerations
Continuous fluid therapy, analgesia, and nutritional support are essential to reduce the
chance of postoperative complications. H2 antagonists (eg, ranitidine) and prokinetics
(eg, metoclopramide and cisapride) can be used to reduce the incidence of gastric ul-
cerations and increase the GI motility.3,18 The use of Elizabethan collars to prevent
self-trauma to surgical wounds may be stressful for rabbits and does prevent caeco-
tropy. Postoperatively, a rabbit’s appetite, fecal and urine output, heart rate, respira-
tory rate, and temperature should be monitored. Excessive handling can be
detrimental to the health status of the rabbits, and, therefore, the frequency of moni-
toring should be adjusted according to the temperament of the patient.8

ABDOMINAL EXPLORATION
Introduction, Indications
The purpose of abdominal exploration is to diagnose and potentially treat abdominal
disease. In rabbits, most abdominal conditions that require surgical intervention are
life-threatening. Abdominal explorations in rabbits are performed for the following
reasons1,7,9:
 Acute abdominal pain due to GI obstruction, urinary tract blockage, peritonitis,
liver lobe, or uterine or bladder torsion
 Chronic abdominal pain and recurring GI stasis due to neoplasia, abscesses,
uterine problems, or adhesions
 Abdominal trauma, causing intra-abdominal bleeding or organ rupture
 Suspected or confirmed complications after previous abdominal surgeries, such
as bleeding, wound dehiscence, or adhesion formation
 Any case of penetrating abdominal injury, including myasis
 Abdominal effusion due to peritonitis
 Extraluminal gas on abdominal radiographs
 To investigate ovarian remnants or adrenal gland disease, biopsy different
organs, and repair hernias
Contraindications
Abdominal exploration may be contraindicated if the patient is not stable. Surgery
often cannot be delayed, however, in cases of active bleeding causing life-
threatening blood loss or in cases of septic peritonitis. In these patients, every attempt
should be made to stabilize cardiovascular parameters prior to and during general
anesthesia.9
Patient Positioning, Preparation, Instruments
The patient is placed in dorsal recumbency, in 10 to 15 reverse Trendelenburg po-
sition. The skin is prepared aseptically for the longest possible incision, from the
caudal half of the thorax to the pelvis, including the inguinal area, to allow the exten-
sion of the incision in both directions, if necessary. A Lone Star retractor (Cooper Sur-
gical, Pleasanton, California) (Fig. 1) is beneficial to improve exposure of the
abdomen.19
Approach
Usually a ventral midline approach is used because it provides excellent bilateral
exposure and an incision through the linea alba is less painful than an incision through
muscle. The length of the incision is variable: an incision from xiphisternum (or xiphoid
process) to the umbilicus allows for examination of the liver and the stomach. An
162 Szabo et al

Fig. 1. A retractor is used to expose the abdominal organs during laparotomy. B, bladder; C,
cecum; L, liver; SP, spleen; ST, stomach; U, uterus.

incision from the umbilicus to the pelvis is useful to assess the bladder and the repro-
ductive tract. Paramedian, flank, and paracostal approaches are infrequently used,
because they do not provide access to the contralateral side.1

Technique
 After the skin incision, the cutaneous blood vessels are cauterized and the linea
alba is identified.
 The abdominal muscles are tented with forceps away from the viscera and the
abdominal cavity is opened through the linea alba with a scalpel blade.
 The interior surface of the linea alba is palpated and adhesions are bluntly broken
down if present.
 The initial incision is extended cranially or caudally, as needed, using scissors,
while the abdominal wall is kept away from the viscera. Fingers or forceps should
be placed between the muscles and the organs to protect the organs.
 Lone Star or Balfour retractor is used to expose the abdominal cavity (see
Fig. 1).19
 The exposed organs should be moistened regularly with warm physiologic saline
and covered with wet laparotomy sponges.
 If peritonitis is present or if the abdominal cavity was contaminated during the
procedure, the abdomen should be lavaged with copious amounts of warm
physiologic saline and then drained.
 Adding antiseptics or antibiotics to the abdominal lavage was recommended his-
torically but they have not shown benefits; moreover, some chemicals can have
detrimental effects. The use of free peritoneal additives, including antibiotics, is,
therefore, not recommended.9
 The abdominal cavity is examined systematically and any necessary interven-
tions are performed.
 The abdominal muscles are closed using simple interrupted or continuous pat-
terns. The authors prefer to use a simple continuous pattern to close abdominal
incisions but recommend interrupting the suture line after every 5 bites with an
Aberdeen knot to prevent suture insufficiency.20 This technique is less time-
consuming compared with interrupted sutures, without the need for cutting
the suture. In addition, if the suture fails anywhere, it acts as an interrupted su-
ture, and, therefore, the failure does not extend along the whole incision.
 Rabbit Soft Tissue Surgery 163

 For closure of the muscle layer in rabbits, 4-0 or 3-0 monofilament, absorbable
suture material is recommended.21,22 Catgut should never be used in rabbits
because of the tissue reaction it causes.1
 Because the holding layer of the abdominal wall is mainly the fascia, it should al-
ways be incorporated in the sutures. Including the peritoneum in the sutures is
controversial. In dogs, suturing the peritoneum could increase the incidence of
postoperative intra-abdominal adhesions9; however, according to an experiment
in rabbits, the closure of the peritoneum results in lower chance of adhesion
formation.23
 The subcutaneous tissue is closed using continuous or interrupted sutures with
4-0 absorbable suture material.
 The skin is closed with continuous intradermal (or subcuticular) sutures using the
same suture material as for the subcutaneous tissue. The use of an Aberdeen
knot is recommended for ending the suture and to bury the knot under the
skin.1 The authors do not recommend external skin sutures because the intrader-
mal sutures combined with tissue glue can provide good aesthetic results and
adequate comfort with a low chance of interfering with wound healing.

Complications
The common complications after abdominal surgeries are heat loss, anorexia, GI sta-
sis, adhesion formation, inadvertent organ penetration, peritonitis, abscessation,
wound infection, seroma development, and abdominal wall dehiscence.9
Adhesion formation is common in rabbits and can interfere with gut motility and
bladder function, block the ureter, and cause discomfort or pain (Fig. 2). Treatment of
adhesions is difficult. Surgery breakdown can be attempted; reoccurrence is possible.
Therefore, prevention adhesions is critical. The organs should be handled gently using
atraumatic methods and they should be kept moist using repeating irrigation and wet
surgical sponges. Any form of chemical irritation (powder from gloves, urine contamina-
tion, and inappropriate suture materials [eg, catgut]) should be avoided, because it in-
creases the risk of adhesions forming. Sterility of the abdominal cavity should be
maintained and any leakage from hollow organs or abscesses should be controlled.

GASTROINTESTINAL SURGERY

For GI surgery, the use of retractors, suction device, magnifying glasses, atraumatic
forceps, ophthalmic forceps, and needle holders is recommended. The use of 6-
0 monofilament, absorbable suture material with tapering needles is recommended.19

Gastrotomy
Indications
In rabbits, gastric surgeries are commonly performed to remove foreign objects (usu-
ally hairballs) and less commonly to treat or diagnose gastric neoplasms or ulcerations
that are life threatening or nonresponsive to medical treatment.24,25
In cases of small intestinal obstruction, the stomach is usually distended and filled
with gas and ingesta. If necessary, the gas and the stomach contents can be released
via an orogastric tube before the abdominal incision is made.26
Generally, gastrotomy is safer and easier to perform than enterotomy due to the
small diameter and thin walls of the small intestine in rabbits. Therefore, if possible,
small intestinal foreign objects should be carefully milked back to the stomach and
removed via gastrotomy.27 Complications, like peritonitis, stricture, and obstruction,
are less common after gastrotomy compared with entrotomy.1
164 Szabo et al

Fig. 2. Adhesion formation (arrowhead) between the caecum and the small intestine.

Technique
 Abdominal incision is made from the xiphoid process to the umbilicus.
 Inspect the abdominal organs and locate and identify all foreign objects and
other abnormalities before making any incision.
 Inspect the stomach wall and palpate its contents to confirm the location of the
foreign object, mass, or ulceration. If the foreign object is in the small intestine,
close to the stomach, milk it back to the stomach.1
 The stomach is isolated from the abdomen with wet, warm laparotomy sponges
(Fig. 3A).
 If possible, make the gastric incision at a hypovascular area, between the lesser
and greater curvatures of the stomach.
 Stay sutures are placed 1 to 2 cm apart from the ends of the planned incision (see
Fig. 3A).
 A full-thickness stab incision is made through the stomach wall and the end of the
suction tube is placed at the opening, thus occluding it (see Fig. 3B).
 The initial stab incision is extended and further suction is used to empty the stom-
ach (see Fig. 3C).
 The foreign object is removed, or the mass or ulceration is excised and submitted
for histopathology.
 The pylorus is palpated to check its patency.
 Rabbit Soft Tissue Surgery 165

Fig. 3. Gastrotomy. (A) Stay sutures are placed in the stomach wall. (B) Suction is used to re-
move fluid from the stomach. (C) Larger particles of the stomach content cannot be
removed with suction. (D) Closure of the stomach wall using an inverting seromuscular
pattern.

 The stomach wall is closed in 2 layers, using 3-0 or 4-0 absorbable, monofilament
suture material with a tapered needle. Both layers should be closed using an in-
verting seromuscular pattern. The first layer includes the serosa, the muscularis,
and the submucosa but not mucosa. The second layer incorporates the serosal
and muscularis layers (see Fig. 3D).
 The abdominal cavity is lavaged using warmed sterile physiologic saline.
 Contaminated instruments and gloves are replaced with sterile ones and the
abdomen is closed routinely, as described previously.
Complications
 Leakage, dehiscence, perforation, peritonitis, stenosis, ileus, adhesions, shock,
and death are possible complications of the GI surgeries.9
Postoperative care
Postoperative supportive care, monitoring, analgesia, fluid, and antibiotic and proki-
netic therapy should be used. Fasting after GI surgery is not necessary for rabbits.
Feeding small amounts of high-fiber herbivore food is recommended 2 hours after re-
covery to maintain the normal intestinal flora and to encourage normal gut motility.26
Enterotomy and Intestinal Biopsy
Indications
The most common indication for enterotomy in rabbits is removal of foreign objects.
Intestinal biopsy is performed to collect samples from neoplasms and other intestinal
wall abnormalities.9,28
166 Szabo et al

Technique
 If an intestinal foreign body is present, try to milk it back to the stomach
and perform gastrotomy or try to milk it toward the large intestine. If the object
reaches the large intestine, the rabbit usually can pass it without any problem.
If the object cannot be moved in either direction, perform an enterotomy to re-
move it.
 The location of the abnormal intestine (foreign object or neoplasm) is identified
and isolated from the abdominal cavity with moistened gauze or surgical
sponges.
 The intestinal contents are gently milked away orally and aborally from the iden-
tified segment.
 To reduce the chance of contamination, the lumen of the intestine could be
occluded temporarily by the fingers of an assistant. Alternatively small and gentle
atraumatic clamps can be used. Stay sutures can be used to manipulate the in-
testine (Fig. 4A).
 The intestinal incision is made at the antimesenteric border, through a healthy
portion of the intestine, distal to the obstruction. The incision should be long
enough to remove the object without tearing the tissue (see Fig. 4B).
 Enteric biopsies are performed using a 2-mm biopsy punch or excising a small
segment of the intestinal wall.
 After removing the foreign object or successful harvesting of the biopsies, lumen
of the intestine is gently cleaned with a swab to reduce the contamination.
 The incision is closed in a simple interrupted or continuous pattern. If possible, to
preserve the lumen, a longitudinal incision is closed transversely. If this method is
used, 1 simple suture is initially placed at the middle of the wound to transpose
the incision to a transverse orientation. The remaining sutures are placed to left
and right from the first one.

Fig. 4. Enterotomy for treatment of a small intestinal obstruction. (A) The small intestine is
occluded by a foreign object (hairball). Note the stay sutures. (B) Incision of the intestinal
wall to exposes the hairball. (C) After closure the intestine using simple continuous pattern,
the intesintal segment is filled with saline to check for leakage.
 Rabbit Soft Tissue Surgery 167

 When placing the sutures, the needle is angled slightly so the serosal surface of
the intestine is engaged slightly farther from the edge than the mucosa. This
method helps to reposition the everting mucosa into the lumen of the intestine.
 The sutures are gently tied to prevent them from cutting through the intestinal
layers. The use of crushing sutures is not recommended.
 After closure of the enterotomy, 1 to 2 mL of sterile, warm saline solution is in-
jected into the lumen of the intestine using a 25-gauge or smaller needle, and
the seal of the sutures is checked while applying gentle digital pressure. If
leakage occurs, additional sutures are placed (see Fig. 4C).
 Because of the small size of the omentum in rabbits, omentalization of the surgi-
cal site is usually not possible.1
 The abdomen is lavaged, the contaminated instruments and gloves are replaced,
and the abdomen is closed routinely.

Small Intestinal Resection and Anastomosis

Indications
Intestinal resection is performed to remove an abnormal intestinal segment due to
intussusception (Fig. 5), stricture, neoplasm, abscess, and ischemia. Any bowel
segment of questionable viability should be resected.9

Technique
 The diseased intestine is identified, exteriorized, and isolated.
 The viability of the intestine is assessed and the portion that needs to be resected
is determined.
 The mesenteric vessels that support the intestinal segment to be removed are
ligated and transected.

Fig. 5. (A) Intussusception in the small intestine. (B) A cotton-tipped applicator is placed in
the lumen of the thin walled intestine to prevent the opposing intestinal walls being su-
tured together during anastomosis. (C) The anastomosis of the small intestine after closure.
168 Szabo et al

 The intestinal contents are gently milked away orally and aborally from the
identified segment.
 Artery forceps can be used to occlude the lumen of the diseased segment
because this portion is removed. The lumen of the intestine of the healthy intes-
tine should be occluded with a gentle, atraumatic temporary method, such as by
the fingers of an assistant.
 The intestine is transected between the forceps and the fingers of the assistant.
To increase the diameter of the lumen, an oblique incision is used.
 If there is a large difference between the lumen diameters of the 2 ends, then use
an oblique incision (45 –60 ) at the narrow end and a perpendicular incision at the
wider. When making the oblique incision, remember the antimesenteric border is
shorter than the mesenteric. Using this method, the oblique incision widens the
lumen of the smaller segment and reduces the disparity between the 2 ends.
 The anastomosis is closed using 6-0 monofilament, absorbable suture material.
The first suture is placed at the mesenteric border; the second one is 180 from
this at the antimesenteric border. The sutures are placed through all layers of the
intestinal wall and gently tied to appose the edges. The use of crushing sutures is
not recommended. To keep the walls of the intestine apart, a sterile cotton-
tipped applicator can be placed into the lumen of the intestine during closure
(see Fig. 5B). After placing the first 2 sutures, the rest of the intestinal walls
can be closed using simple interrupted or simple continuous sutures. After clos-
ing one side, the intestine is flipped over and the other side is closed in a similar
manner (see Fig. 5C).
 After closure, the sutures are inspected and the lumen of the intestine is filled with
warm saline to test for leakage and lumen patency.
 The mesentery is closed with simple continuous sutures using 6-0 monofilament
suture material while taking care not to damage the arcadial vessels around the
defect.
 The abdomen is lavaged, the contaminated instruments and gloves are replaced,
and the abdomen is closed routinely.

LIVER SURGERY
Indications
Liver biopsy is performed to diagnose abnormalities of the liver, for example,
neoplasia, hepatitis, and hepatic lipidosis.29 The purpose of liver lobectomy is to
remove a lesion, such as neoplasia, abscess, or a torsed lobe.

Contraindications
Liver disease often causes coagulation problems and liver biopsies may cause hem-
orrhage. Therefore, it is essential to assess the coagulation status of the rabbit before
surgery and postpone the intervention if the rabbit has coagulopathy.4 Other contra-
indications include moderate to severe anemia, moderate to severe thrombocyto-
penia, decreased renal function, and poor overall health status for general
anesthesia. Contraindications for liver lobectomy may include diffuse, disseminated,
or metastatic neoplastic disease.9

Presurgical Considerations
Liver problems are usually diagnosed by blood biochemical analysis. Rabbits do
not have a liver-specific enzyme, but, similar to dogs and cats, measuring the levels
of aspartate aminotransferase and g-glutamyltransferase enzymes and the
 Rabbit Soft Tissue Surgery 169

concentration of bilirubin, bile acids, and total protein can be useful.4,29 Liver abnor-
malities can also be diagnosed with imaging methods, such as radiography, ultra-
sound, CT, MRI, and endoscopy.
Before liver surgery, prophylactic antibiosis against aerobes and anaerobes (eg,
enrofloxacin combined with metronidazole) is recommended.3,8 If hepatic function
is compromised, the anesthetic protocol should be adjusted accordingly.

Technique
 For liver surgeries, the rabbit is placed in dorsal recumbency and the skin is sur-
gically prepared for cranial abdominal exploration.
 After a standard midline cranial abdominal incision, retractors are used to expose
the abdominal contents and the abdominal organs should be systematically
explored.
 The omentum and the stomach are gently reflected and the whole liver is in-
spected thoroughly.
 The area of interest is identified and isolated. If the abnormality is diffuse through
much of the liver, a marginal area is chosen for sampling to reduce the chance of
hemorrhage.
 Regardless of the biopsy method, gentle handling of the sample is important.

Punch biopsy
A skin biopsy punch can be used to take small liver samples (see Fig. 13). Metzen-
baum scissors are used to transect the base of the fragment to avoid trauma to the
biopsy fragment itself and then the sample is gently removed (Fig. 6). If hemorrhage
from the sample is excessive, interrupted capsular sutures can be placed using appro-
priately sized, monofilament absorbable suture. Alternatively, an absorbable gelatin
sponge can be placed at the biopsy site to encourage clot formation.

Guillotine suture biopsy or partial lobectomy

Guillotine suture biopsy is useful to sample or remove peripheral liver lesions. A loop of
absorbable suture material is placed around a peripheral segment of liver tissue
(Fig. 7A) and carefully tightened (see Fig. 7B), cutting through the liver tissue and
ligating the blood vessels. Once a ligature is placed, the isolated hepatic tissue can
be excised.30

Excisional wedge biopsy with overlapping guillotine sutures

Full-thickness, overlapping, interrupted mattress sutures are placed in a peripheral re-
gion of the liver lobe and ligated, forming a V-shape. The wedge between the rows of
sutures is removed using sharp dissection or electrosurgery (see Fig. 7C).

Fig. 6. Liver biopsy. (A) An 8-mm biopsy punch is used to take a sample from the liver. (B)
The biopsy sample is gently removed from the liver.
170 Szabo et al

Fig. 7. Guillotine technique for liver biopsy. (A) A loop of absorbable suture material is
placed around a peripheral segment of a liver lobe and tightened. (B) The isolated liver tis-
sue is excised using Metzenbaum scissors. (C) The isolated liver tissue is removed after exci-
sional wedge biopsy with overlapping guillotine sutures.

Total lobectomy
Torsion of a liver lobe (usually the caudate or the right lateral lobe) is increasingly diag-
nosed in rabbits (Fig. 8).31–38 The treatment of the liver lobe torsion is total lobectomy
of the affected lobe(s).34 When performing total lobectomy, the vessels at the base of
the lobe are ligated using monofilament, absorbable suture material, vascular clips
(eg, Hemoclip, Teleflex, Wayne, Pennsylvania) (see Fig. 8), surgical stapling devices,
or sealing systems (LigaSure, Covidien, Dublin, Ireland). Because the blood vessels
are short and broad, double ligation or stapling is recommended. Once ligatures
have been securely placed, the lobe is carefully transected and removed.30

Fig. 8. Liver lobectomy for treatment of liver lobe torsion. (A) Abdominal exploration after
liver lobe torsion. A torsed liver lobe (arrow) is dark and swollen. Bloody, free abdominal
fluid is present. (B) Vascular clips are used to occlude the blood vessels during lobectomy
due to liver lobe torsion.
 Rabbit Soft Tissue Surgery 171

Complications and Postoperative Care

The most common complication during and after liver surgery is intra-abdominal
bleeding. The rabbit is placed in dorsal recumbency immediately after the surgery
to let the weight of the liver press the biopsy sites against the abdominal wall and
reduce any bleeding. The patient is monitored for signs of bleeding for 24 to 48 hours
after the surgery.31,32

URINARY TRACT SURGERY

Urinary tract surgery in rabbits is challenging because of the small size of the patients.
Urolithiasis is a common occurrence due to the unique calcium metabolism of the rab-
bits and high calcium excretion in the urine.39

Presurgical Consideration
Diagnostic tests should be performed according to the case, including urinalysis and
urine bacterial culture.40 Radiographs are useful to diagnose kidney and bladder
stones; both plain and contrast radiographs41 can be used along with ultrasonogra-
phy.42 Cystoscopy and laparoscopy also may be used.40
A maintenance fluid rate of 100 mL/kg/d is recommended, with increases as
necessary to correct any azotemia or dehydration. Urine production, body weight,
and cardiovascular function should be closely monitored to prevent volume over-
loading, especially at higher fluid rates. IV fluid therapy during surgery at up to
10 mL/kg/h should be used, again with careful monitoring to prevent fluid
overload.1

Patient Preparation and Instruments

For kidney surgery, a cranial abdominal approach should be used, with a midline inci-
sion initially from just caudal to sternum down to umbilicus. For bladder surgery, a
caudal laparotomy approach is used, with a midline incision of the caudal third of
the abdomen stopping a centimeter or so cranial to the pelvis is advised.
Absorbable, monofilament suture material should be used in kidney, ureter, and
bladder surgeries.1,9

Postoperative Complications
Complications include bleeding, hematuria, and urine leakage into the abdomen
(which may trigger peritonitis). Urine flow blockage may occur due to blood clots,
debris, adhesions, and strictures. Fluid diuresis during and after surgery and copious
flushing reduce this risk.

Postoperative Care
Prolonged fluid therapy is necessary, especially after kidney surgeries. Antibiotics
based on culture results should be considered if bacterial infections are suspected
or contamination during surgery has occurred. Monitoring urine output and urinalysis
in the postoperative period is important.

Kidney surgeries
The rabbit is placed in dorsal recumbency and the entire ventral abdomen surgically
prepared with an initial midline abdominal exploration incision made from sternum
to the umbilicus.
172 Szabo et al

Renal Biopsy
Renal biopsy is performed to make a definitive diagnosis of kidney disease and to
determine prognosis for nephropathy, kidney masses, and neoplasms. Contraindica-
tions include patients with bleeding disorders, large intrarenal cysts, hydronephrosis,
perirenal abscesses, and urinary tract obstruction.
Technique
 Both kidneys should be examined in every case and both kidneys should be
sampled if bilateral disease is suspected.
 The kidney is bluntly separated from the parietal peritoneum and gently held be-
tween 2 fingers while a section of renal tissue is removed by making 2 incisions
along the greater curvature of the kidney coming together at a 60 angle, thus
removing a wedge of tissue (Fig. 9). The sample is gently removed and the inci-
sion is closed using 4-0 absorbable suture material.
 For smaller samples, core needle biopsy can be performed using spring-loaded
biopsy needles (16–18 G), manual Tru-Cut biopsy needle (CareFusion, San
Diego, California), or similar tools. Manual devices are less satisfactory because
they may produce fragmented tissue samples. If biopsy needles are used, then
collect at least 2 samples, each longer than 1 cm.9 Bleeding after sampling
can be controlled by applying digital pressure or using a cotton-tipped applicator
or surgical sponge.
Nephrotomy
The indications of nephrotomy include removal of a kidney stone, masses, or
neoplasm from the renal pelvis and exploration of bleeding into the renal pelvis. The
main contraindication is that nephrotomy reduces the renal function significantly
(30%–40% in dogs and cats); therefore, it is not advisable in cases of impaired renal
function.42
Technique
 The kidney is bluntly separated from the parietal peritoneum and gently held be-
tween 2 fingers while the vessels at the hilus of the kidney are clamped using
atraumatic and reversible methods (Fig. 10).
 A sagittal incision is made along the midline, and the parenchyma is bluntly
dissected to expose the renal pelvis. The urolith (Fig. 11), mass, or abscess is
removed, and the source of any bleeding is explored.

Fig. 9. Kidney wedge biopsy.

 Rabbit Soft Tissue Surgery 173

Fig. 10. Nephrotomy. (A) The vessels of the kidney are clamped during nephrotomy, while
the ureter (arrowhead) remained patent to allow for catheterization. (B) Removal of the
renal calculi. (C) A catheter is inserted through into the ureter to check its patency. (D)
The 2 halves of the renal cortex are apposed using horizontal mattress sutures. (E) The kid-
ney capsule is closed using a simple interrupted or continuous suture pattern.

 The pelvis and the parenchyma are sampled for bacterial culture and the
exposed tissue and the pelvis are gently flushed with warm, sterile saline to re-
move any debris or blood clots.
 A 3F (1-mm) size catheter is inserted through the pelvis into the ureter to check its
patency, which is only possible if the ureter has not been clamped previously (see
Fig. 10C).

Fig. 11. Nephrectomy and nephroureterectomy. (A) The renal artery is ligated using vascular
clips. (B) During nephroureterectomy, the ureter (arrowheads) is followed and detached
from the peritoneum along its length and removed with the kidney.
174 Szabo et al

 The surgical incision in the renal cortex is closed using horizontal or cruciate
mattress sutures (see Fig. 10D).
 The kidney capsule is closed with simple interrupted or continuous suture pattern
using 4-0 absorbable suture material (see Fig. 10E). The clamps from the vessels
of the kidney are removed.
 A lateral approach, caudal to the last rib, has also been described but does not
allow inspection of the contralateral kidney.43

Pyelolithotomy
Pyelolithotomy is an incision into the renal pelvis and proximal ureter and is indicated
when a urolith is found in the extrarenal region of the pelvis of the kidney. This surgery
only can be performed if the pelvis is distended due to of obstruction in urine flow
through the ureter. The main advantages are that less renal damage is caused
compared with nephrectomy because there is no damage to the parenchyma, no
need to occlude the renal vessels, and the postsurgical complications are less
common.1

Technique
 The approach is the same as for nephrotomy.
 A longitudinal incision is made on the distended pelvis over the calculus, and the
renal stone is removed. The pelvis is sampled for bacterial culture then gently
flushed with warm, sterile saline.
 A 3F (1-mm) size catheter is inserted through the incision into the ureter to check
its patency. The incision is closed with simple interrupted or continuous suture
pattern using 5-0 absorbable suture material. Transverse closure is recommen-
ded to maintain a wider lumen.1,9

Nephrectomy
Nephrectomy, the surgical removal of a kidney, is indicated if there is extensive, irre-
versible renal disease, which could worsen the status of the patient if the kidney is left
in place. Examples include severe, irreversible renal trauma, neoplasm, abscess,
hydronephrosis,44 or pyelonephritis that is not responsive to antibiosis or causes
uncontrollable pain, urine leakage or hemorrhage.1,9
Contraindications are significantly impaired function of the contralateral kidney. Pre-
surgical diagnostics are aimed at establishing adequate renal function in the contralat-
eral kidney. Biochemistry and urinanalysis in addition to an excretory pyelogram or a
glomerular filtration study should be considered.

Technique
 Approach is the same as for nephrotomy.
 The kidney is gently lifted and rotated medially and the hilus, ureter, and renal ar-
tery and vein are identified. The renal vessels and the ureters are individually
clamped and ligated using 4-0 absorbable suture material or with vascular clips
(see Fig. 11A).
 Nephroureterectomy (removal of the ureter and the kidney) is performed if the
ureter is diseased. The ureter is followed and gently detached from the perito-
neum along its length (see Fig. 11B). The distal end of the ureter is ligated
1 cm from its insertion into the urinary bladder, transected above the ligature,
and removed.
 Rabbit Soft Tissue Surgery 175

Ureterotomy
Ureterotomy is an incision into the ureter and this procedure is indicated for removal of
a urolith from the ureter. It carries a significant risk of postoperative stricture due to
the narrow diameter of the ureters in rabbits. An alternative method that reduces
this risk is retrograde flushing of the stone to the renal pelvis and removal with
pyelolithotomy.

BLADDER SURGERIES
Cystotomy and Cystectomy
Cystotomy is the surgical incision into the urinary bladder and cystolithectomy is the
removal of urinary bladder calculi through a cystotomy. Indications for these proce-
dures are removal of large bladder stones, removal of urethral stones that can be
flushed back to the bladder, repair of bladder rupture, biopsy or removal of bladder
masses, and investigation of chronic, refractory cystitis that is resistant to medical
treatment. Small stones and hypercalciuria (bladder sludge) may be removed from
the bladder with catheterization and careful, repeated flushing although urethral
swelling and blockage may be seen after this method.
Cystectomy is the removal of a portion of the bladder to treat bladder neoplasm,
polyps, bladder wall necrosis, and traumatic injuries. It is performed in a similar
approach and manner to a cystotomy; 65% to 70% of the bladder wall can be
removed without interfering with the function of the bladder if the trigone is left intact
and ureters are not damaged.1,9

Technique
 A caudal abdominal approach is used, taking care not to inadvertently enter the
bladder, if distended. The healthy bladder is thin walled, but bladder wall may be
thickened if chronic inflammatory disorders are present.
 The bladder is identified, gently lifted, exteriorized, and moistened and gauze or
surgical sponges packed around it. Stay sutures are placed in the bladder wall
cranial and caudal to the planned incision. To reduce contamination the urine,
the bladder should be drained with a syringe and the needle prior to incision.
 The incision is made through an avascular portion of the bladder wall. A chroni-
cally inflamed bladder wall bleeds easily.
 Remove the calculi using a surgical spoon or forceps. Calculi may adhere to the
inflamed bladder wall or be buried deep within mucosal fold, and care should be
taken not to damage the bladder wall during calculi removal. Calculi may be
found deep in the neck of the bladder, far from the incision site.
 If there are calculi lodged in the urethra, retrograde flushing into the bladder from
the external urethral orifice, using a urinary catheter, should be performed. If
there are multiple small stones and/or urethral stones, it is recommended to
place this catheter before surgery.
 Swabs of the bladder wall for bacterial culture and sensitivity testing should be
collected, if urine was not collected prior to the incision. Biopsy samples of the
bladder wall for aerobic culture and for histopathology may be collected, if
indicated.
 The bladder cavity is gently flushed with warm, sterile saline to remove blood
clots or debris. The urethra should be gently flushed with saline, either retrograde
or normograde, with a sterile catheter inserted through the bladder incision.
 The bladder wall is closed using single or continuous inverting suture pattern
(Lembert or Cushing) without the suture material entering the bladder lumen. If
176 Szabo et al

the suture material penetrates the bladder wall, it can act as a nidus of infection
and increase the chance calculi recurrence.
 Use 4-0 or 5-0 absorbable, monofilament suture material. If the bladder wall is
thin or fragile, a double layer closure is recommended.45
 Fibrin sealants are used in human medicine and are a future consideration for
bladder wall closure.46
 The bladder incision is checked for leakage by filling the bladder with sterile
saline.

Complications
Complications include rupture or perforation of the overdistended bladder, especially
during the abdominal incision, as well as urine leakage from the bladder incision site. A
chronically inflamed bladder may form adhesions to the surrounding intestine or
uterus. Iatrogenic damage of the ureters may occur if the incision is made into the dor-
socaudal aspect of the bladder. The risk of postsurgical urine leakage can be pre-
vented by checking for leakage after closure of the bladder.

Tube Cystostomy (Prepubic Catheterization)

Tube cystotomy is a temporary solution to alleviate the clinical signs of urethral
obstruction or bladder atony, by placing a Foley catheter into the bladder thus bypass-
ing the urethra.1
 The approach may be midline, where a small incision caudal to the umbilicus is
made, or in the inguinal approach, where a 2-cm to 3-cm oblique inguinal incision
is made over the bladder.
 Once the incision is made, locate the bladder, and place stay sutures and a
purse-string suture into the bladder wall.
 Place the tip of the Foley catheter into the abdominal cavity through a separate
small stab incision. Make a small stab incision into the bladder within the purse-
string suture and introduce the Foley catheter into the bladder lumen. Inflate the
balloon with saline, and secure the catheter within the lumen by tightening the
purse-string suture. Suture the bladder to the body wall with several interrupted
absorbable sutures.
 Close the initial incision, and secure the catheter to the skin using a Roman
sandal–type suture.

Prescrotal Urethrotomy
Prescrotal urethrotomy is the incision into the urethra of the male rabbit, usually to
remove urethral calculi causing blockage of urine flow.1 Urethral blockage is often
initially a medical, not surgical emergency. Hyperkalemia may be present due to
post–renal obstruction. Appropriate fluid therapy and bladder drainage may be neces-
sary to correct electrolyte abnormalities, prior to anesthesia.

Technique
 The most common location of the blockage is the distal urethra, and forced,
manual expression of the bladder is not recommended because of the risk of
bladder rupture.
 In some cases, the urolith can be flushed back to the bladder and cystotomy can
performed instead of urethrotomy. Postoperative stricture formation is a com-
mon complication after urethrotomy so preference should be given to cystotomy,
if possible.
 Rabbit Soft Tissue Surgery 177

 The pubic area and the hemiscrotal sacs are surgically prepared. And the
scrotum is reflected to allow the exposure of the surgical area
 A sterile urinary catheter is placed into the urethra reaching the level of the cal-
culus and measuring the length of the catheter to the skin helps to identify the
appropriate location of the skin incision
 A vertical incision is made in the skin on the lateral side of the penis at the level of
the calculus, perpendicular to the urethra; then the stone is located in the urethra
by digital palpation. Next, a midline longitudinal incision is made into the penis
and the urethra directly over the stone and the urolith is removed. The catheter
should be further advanced to check the patency of the urethra. Any hemorrhage
is controlled by digital pressure.
 The urethra is closed using 5-0 monofilament, absorbable suture material in a
continuous suture pattern
 The subcutis and the skin are routinely closed and the catheter is removed.

Complications
Complications include obstruction of the urine flow secondary to tissue swelling,
fibrosis, and necrosis. Urine leakage from the wound into the subcutis can lead to
infection, irritation, and stricture formation.

OVARIOHYSTERECTOMY AND OVARIECTOMY

Indications
Rabbits have a bicornuate duplex uterus, which lacks a uterine body. The separate
uterine horns have each their own cervix and enter into a single long vagina. The indi-
cations for ovariohysterectomy are to prevent breeding, prevent uterine and ovarian
neoplasms and other diseases, reduce the incidence of mammary gland disease, pre-
vent false pregnancies, and reduce hormonal territorial behavior.47,48 Uterine adeno-
carcinoma is the most common tumor in female rabbits.49 The reported incidence of
uterine adenocarcinoma is up to 75% in 7-year-old female rabbits.50 Surgery is easier
once a rabbit has reached puberty because the uterus enlarges and the ligaments
become slightly looser (between 6 and 9 months); however, surgery is best not
delayed too long because significant fat can be laid down around the uterus and
ovaries.1 Rabbits can be spayed during pregnancy or pseudopregnancy but the sur-
gery should be delayed after giving birth until the babies are weaned at 4 to 5 weeks of
age.1 Ovariectomy can be considered in a doe without evidence of uterine disease.
Ovariectomy should be limited to young animals between 6 and 12 months of age.1,51

Presurgical Considerations
Diagnostic tests should be performed based on an animal’s age and suspected con-
current diseases and may include urinalysis, biochemistry, and hematology. Thoracic
radiographs should be taken in animals older because uterine adenocarcinoma readily
metastasizes to the lungs.1 Contraindications include planned future use as a
breeding doe, severe systemic disease, and secondary spread of uterine neoplasia.

Patient Positioning, Preparation, and Approach

The rabbit is placed in dorsal recumbency and the caudal half of the abdomen clipped
and surgically prepared. For ovariohysterectomy, a midline approach is recommen-
ded to the caudal abdomen, with the initial incision made at the level of the last
(inguinal) nipples.
178 Szabo et al

Technique
 The initial incision should be approximately 2 to 3 cm, approximately midway be-
tween the umbilicus and the pubic symphysis, which often allows for the exteri-
orization of the uterus while keeping the GI tract within the abdomen. If there is a
large amount of fat in the mesometrium around the uterus, the incision may need
to be extended. Care must be taken when entering into the abdomen or extend-
ing the incision because the bladder and the cecum are in apposition with the
body wall.
 The uterine horns are carefully exteriorized, with particular care used to draw the
ovaries out because the section between the cranial end of the uterus and the
ovary is weak and may tear (Fig. 12A).
 The ovary, fallopian tube (or salpinx) and associated fat pads are identified and
carefully exteriorized (see Fig. 12A). The ovarian ligament can be transected to
facilitate the exteriorization (Fig. 12B). Two artery forceps are clamped on the
ovarian pedicle. Two ligatures are placed between the forceps using 3-0 or 4-0
absorbable suture material or vascular clips (see Fig. 12C). The pedicle is trans-
ected above the second ligature and checked for hemorrhage before being
returned to the abdomen. The ovary should be checked to ensure all ovarian tis-
sue has been removed.
 The same procedure is performed on the contralateral ovary.
 The uterine vessels within the mesometrium are identified and ligated on either
side of the uterus using absorbable suture material or vascular clips (see
Fig. 12D). The fat may be profuse and obscure the vessels.

Fig. 12. Ovariohysterectomy. (A) Visualization of the female reproductive tract after caudal
midline laparotomy. (B) The ovarian ligament is transected to help the exteriorization of the
ovary. (C) Vascular clips are used to ligate the ovarian artery. (D) The uterine vessels are
ligated using vascular clips. FT, fallopian tube; O, ovary; OA, ovarian artery; OL, ovarian lig-
ament; U, uterine horns; V, vagina.
 Rabbit Soft Tissue Surgery 179

 The double cervix is clamped and double ligated with 3-0 or 4-0 synthetic
absorbable suture and transected above the second ligature. One or both liga-
tures should be transfixing.
 If the uterine horns or the cervixes appear diseased, all tissue should be removed
and the transection performed at the proximal vagina. Because the vagina is not
sterile, care should be taken to close the lumen after transection.

Complications
Complications in the immediate postoperative period include GI stasis and wound
healing complications and self-inflicted wound trauma. Longer-term problems include
adhesion formation.52 According to Harcourt-Brown and Chitty,1 transection and liga-
tion of the vagina could result in urine leakage into the abdomen and could cause local
peritonitis and adhesions. Good postoperative care is vital to reduce complications.
This topic is discussed in the article elsewhere in this issue by Colopy and colleagues.

ORCHIECTOMY (CASTRATION)
Indications and Presurgical Considerations
The indications for castration (or orchiectomy) of male rabbits include prevention of
breeding; reduction in aggression, sexual behavior, and urine marking, particularly if
done before full sexual development47; and prevention of testicular neoplasia.53–55
Rabbits can be castrated as soon as testicles are palpable within the hemiscrotal
sacs, which can be as early as 10 weeks of age.1 Contraindications include planned
future use as a breeding male and systemic disease.

Patient Positioning, Preparation, and Instruments

General anesthesia is induced, the rabbit placed in dorsal recumbency, and the pre-
scrotal area, hemiscrotal sacs, and prepuce are clipped taking care not to traumatize
the delicate skin. Local anesthetic can be injected subcutaneously at the incision site
and testicular blocks are performed. The surgical site is aseptically prepared.

Approach
The surgical approach may be scrotal, prescrotal, or abdominal.47,48,56 The scrotal
open-to-closed technique has the advantage of short procedure time but it requires
2 incisions; the scrotal skin is easily irritated during surgical preparation; and contam-
ination of the wounds through cage bedding is possible. The prescrotal approach re-
quires only a single incision and sterile preparation of the surgical site is easier
compared with the scrotal approach. The procedure time, however, is usually longer.
The abdominal approach requires entering the abdominal cavity, is therefore more
painful, and should be reserved for repair of inguinal or hemiscrotal herniation or treat-
ment of true cryptorchism.56
Orchiectomy in rabbit should always be performed closed or in an open-to-closed
manner to prevent herniation of the intestine or urinary bladder through the open
inguinal canals.47,48,56

Technique
Scrotal approach
 Incise through the scrotal skin on ventral aspect of the testicle (Fig. 13A). As the
testicle bulges through the incision, gently free and exteriorize it. Gently pull the
testicle and tunic caudally exposing the pedicle of the testicle with vessels and
180 Szabo et al

Fig. 13. Scrotal castration technique. (A) The skin of the scrotum is incised and the vaginal
tunic is exposed. (B) The vaginal tunic is opened and the testicle is gently pulled to expose
the vessels and vas deferens within the tunic. (C) The vaginal tunic is clamped twice with ar-
tery forceps at the base of the pedicle. The ligatures will close the tunic and prevent the her-
niation of the abdominal organs.

vas deferens within the tunic. Opening the vaginal tunic allows removing the fat
pad within the tunic and the testicle can be exteriorized easily (see Fig. 13B).
 Carefully cut the attachment between the caudal end of the tunica vaginalis and
the scrotal skin, allowing the testicle to be exteriorized further.
 Clamp the pedicle of the tunica vaginalis twice with artery forceps toward the
base of the pedicle (see Fig. 13C).
 Ligate each clamped site firmly in the crushed tissue with 3-0 or 4-0 synthetic
absorbable suture, thus ligating the vessels and vas deferens within the tunic
and closing the inguinal canal, if the tunic was opened previously.
 If the rabbit is large or obese or if the tunic is abnormally thickened, then a trans-
fixing suture may be used for safety or the vessels should be ligated individually
before closing the tunic.
 The vessels, vas deferens, and tunic are transected above the ligature and the
testicle is removed; then, the ligatures are checked for hemorrhage.
 No skin sutures are required and are better avoided because they may stimulate
self-trauma; tissue glue may be used if necessary.

Prescrotal approach
 A single midline prescrotal incision is made (Fig. 14A) and blunt dissection
toward the inguinal area is performed.
 The testicular pedicle is grasped and retracted and testicle is drawn up and out
(see Fig. 14B). The attachment between the caudal end of the tunica vaginalis
and the scrotal skin is bluntly separated. The vaginal tunic can be opened to re-
move the fat fad and to make the pedicle thinner and easier to ligate. The pedicle
is then freed from the fascia, crushed, and ligated (as described previously), thus
closing the vaginal tunic (see Fig. 14C). The tunic distal to the ligation should be
resected.
 The skin incision should be closed in 1 or 2 layers.
 Rabbit Soft Tissue Surgery 181

Fig. 14. Prescrotal castration technique. (A) A single midline prescrotal incision is made cra-
nial to the base of the scrotum. (B) The testicular pedicle is grasped and retracted and the
testicle within the vaginal tunic is pulled out. (C) The pedicle of the testicle is ligated, which
closes the vaginal tunic and prevents the herniation of the abdominal organs.

THORACIC SURGERY
Introduction
In comparison to dogs and cats, the thoracic cavity of rabbit is much smaller in relation
to the abdominal cavity, making surgical interventions challenging.57 Indications for
thoracotomy in rabbits include removal of thoracic masses (eg, thymoma), primary
lung neoplasms, lung abscesses or foreign objects, and lung lobectomy in cases of
lung lobe torsion.

Presurgical Considerations
Routine diagnostics for thoracic and lower respiratory disorders may include diag-
nostic imaging, bronchoalveolar lavage, tracheoscopsy/bronchoscopy, fine-needle
aspiration, cytology, and bacterial culture and susceptibility testing.58
Intermediate positive-pressure ventilation (IPPV) is required for thoracotomy proce-
dures. To ventilate the patient during the thoracotomy, an endotracheal tube should
be placed13,14 and sealed and either manual or mechanical ventilation performed.

Thymoma Removal via Median Sternotomy

The thymus is found in the mediastinum, cranioventral to the heart, and in rabbits it
does not involute but persists for life.59 Thymomas are the most common mediastinal
tumors in rabbits.60 On radiographs they appear as a large soft tissue mass in the
182 Szabo et al

cranial thorax. They are usually histologically benign and rarely metastasize but they
have tendency to recur after incomplete removal. Thymomas are usually not invasive
but can be adhered to the pericardium.1,61 Thymic carcinomas with metastatic
tendency in rabbits are rare.62
The perioperative mortality rate in rabbits after surgical removal of thymomas has
been reported to be high. In 1 case series, 5 of 9 rabbits died within 3 days of surgery;
the survival time was 0 to 955 days (median 3 days).61
Thymomas are radiosensitive so radiation therapy could be an alternative to sur-
gery, but the proximity of the lung and heart limits the recommended dose of radia-
tion.63 The short-term survival rate after radiation therapy is 80% to 85%, which is
higher than the perioperative survival rate after surgery (40%–50%),61 but the compli-
cations (radiation-induced myocardial failure, pneumonitis, and pulmonary fibrosis)
and recurrence are more common compared with surgical excision.64,65 Andres and
colleagues64 treated 19 rabbits with radiation therapy and 3 rabbits died during the
first 14 days; the median survival time of the remaining animals was 727 days. Radi-
ation therapy can be the sole therapy or combined with surgery, if surgical removal
is incomplete.64
There is limited information regarding the efficacy of chemotherapy in the manage-
ment of thymomas in rabbits; however, prednisolone can be used postoperatively or
after radiation therapy.65 If cystic lesions are present, draining them can temporarily
alleviate the dyspnea and improve quality of life.61

Technique
 Midline sternotomy is recommended for thymoma removal to allow access to
both sides of the thoracic cavity.66 The rabbit is placed in dorsal recumbency.
The skin is shaved and surgically prepared from the neck to the cranial portion
of the abdomen. An intercostal nerve block with bupivacaine (2 mg/kg) should
be performed.9
 A midline skin incision is made from 2 to 3 cm cranial to the manubrium to the
xiphoid process.
 Remaining on midline allows dissection between muscle layers (Fig. 15A). If
necessary, the sternocephalicus and sternohyoideus muscles are bluntly sepa-
rated to expose the sternal bone.
 The exposed sternum is cut perpendicular in the midline, with an oscillating saw
or diamond cutting disc attached to a rotary tool (see Fig. 15B).
 After accessing the thoracic cavity, IPPV is initiated.13,14 IPPV is performed
gently and carefully to prevent the overinflation of the lungs. The inflating pres-
sure should be less than 10 cm H2O and the lung should not turn pale or expand
out from the chest.1,9
 After osteotomizing the first few sternebrae, moistened surgical sponges are
placed along the edges of the sternotomy site and a retractor (see Fig. 15C) is
used to stabilize the thorax and facilitate the careful transection of the remaining
sternebrae.
 The last 1 or 2 sternebrae should be left intact to stabilize the thorax during recov-
ery. If the goal of the sternotomy is to explore the caudal half of the thorax, then
the manubrium should be left intact and the last sternebrae can be cut through.
 The thymic mass is identified and gently and bluntly dissected from the surround-
ing tissue. Large amounts of fat can be found in the thorax, even in rabbits in
normal body condition (see Fig. 15C).
 At the thoracic inlet, caution should be exercised when dissecting the mass from
the jugular and subclavian veins and from the carotid and subclavian arteries.
 Rabbit Soft Tissue Surgery 183

Fig. 15. Thoracotomy via median sternotomy. (A) A midline skin incision is made and if
necessary the sternocephalicus and sternohyoideus muscles are bluntly separated to expose
the sternal bone. (B) A rotary tool is used to cut through the sternum midline, perpendicular
to the bone. (C) Moistened gauze or surgical sponges are placed along the edges of the ster-
num and a retractor is used to open the thorax. (D) Closure of the median sternotomy
wound.

 After removing the thymic mass, the thorax is flushed with warm saline and any
blood clots and debris are removed. The saline is removed with suction.
 An indwelling thoracic drain is placed if ongoing fluid or air accumulation is
expected in the thorax.
 The sternebrae are apposed using preplaced monofilament material, with simple
interrupted sutures placed circumferentially around the sternabrae (see
Fig. 15D).
 The muscle, subcutaneous, and skin layers are closed routinely.
 The excess air from the thoracic cavity is removed and the lungs inflated using
the chest drain or a temporary small red rubber tube is left in the chest during
closure for immediate postoperative evacuation and then pulled once the lungs
are reinflated (Fig. 16).

Fig. 16. Closure of a lateral intercostal thoracotomy wound: a small rubber tube is left in the
thorax to evacuate the air from the chest after closure and then it is pulled out.
184 Szabo et al

Complications
Most complications occur during and until 10 days after the surgery. The most com-
mon complication after thoracotomy is acute perioperative death.61 This may be
related to pain, stress, or anesthetic complications.
Lung Lobectomy via Lateral Intercostal Thoracotomy
Indications
Lateral intercostal thoracotomy is performed to remove thoracic abscesses, a lung
lobe after torsion, or primary lung neoplasms. Thoracic abscesses in rabbits are com-
mon, probably underdiagnosed, and often asymptomatic. They are caused by a
variety of bacteria.1
Technique
The rabbit is placed in lateral recumbency, the affected side facing the surgeon, and
the patient preparation for surgery is similar to that for medial thoracotomy.
 The skin incision is made at the caudodorsal border of the scapula.
 The latissimus dorsi muscle is incised from ventral to dorsal.
 The thoracic inlet and the first rib are identified by palpation beneath the latissi-
mus dorsi muscle.
 The serratus ventralis muscle is separated and the scalene muscle is transected
along the fifth rib.
 The intercostal muscles are transected and the ribs are spread with a retractor.
 Positive pressure ventilation is started immediately after accessing the thoracic
cavity.
 The diseased lung lobe is lifted from the thoracic cavity and the short bronchus
and vessels are ligated with absorbable suture material or with vascular clips.
The lobe is removed and the bronchus is checked for air leakage by filling the tho-
rax chest cavity with warmed sterile saline solution. The saline is thoroughly
removed form the thorax using suction.
 The excess air from the thoracic cavity is removed and the lungs inflated using
the chest drain or a temporary red rubber tube, similarly to median thoracotomy
(see Fig. 16).
 The thoracic wall is closed using preplaced absorbable monofilament sutures en-
circling the ribs cranially and caudally from the wound.
 The closure and postoperative care are similar to those for median sternotomy.
Thoracostomy Tubes (Chest Drain Placement)
A chest drain facilitates the removal of air and fluid from the pleural space, eliminating
the need of needle-guided thoracocentesis postoperatively. It can be placed in a
closed fashion for air or fluid removal prior to surgical intervention or in an open fashion
during any thoracotomy procedure. Advantages to placing thoracostomy tubes intra-
operatively include the ability to protect intrathoracic structures as well as guide the
thoracostomy tube to its desired location.1
Technique
 A stab incision is made at the level of the 10th intercostal space at the dorsal side
of the chest.
 The tip of the drain with the trocar is advanced cranially, creating a subcutaneous
tunnel to the level of the eighth intercostal space. The trocar is then gently
advanced through the eighth intercostal space, perpendicular to the thoracic
wall, avoiding the caudal edge of the eighth rib.
 Rabbit Soft Tissue Surgery 185

 Only a short portion of the trocar is advanced into the thorax to prevent any in-
juries of intrathoracic organs. The drain on the trocar is pushed forward to cover
the sharp end. Both the trochar and the drain are advanced superficially, parallel
to the thoracic wall to the level of the second rib. After reaching the desired po-
sition, the trocar is pulled back while the drain is held in position.
 The drain is occluded immediately with artery forceps and a connector with a
3-way stopcock. The artery forceps is removed and the excess air is gently
drained with a 3–6 mL syringe from the chest. The authors suggest no more
than 3 mL negative pressure when using a syringe.
 The 3-way tap is closed and the ports are sealed.
 The chest drain is sutured to the chest wall with Roman sandal tie around the
tube, the site of insertion is covered with a dressing, and the tube is bandaged
to the chest.
Postoperative care
Gloves should be worn when handling thoracostomy tubes to prevent ascending bac-
terial infection. The connections are regularly checked to ensure that a closed system
is maintained. The bandage is changed daily. An Elizabethan collar could be consid-
ered to prevent interference with the tube.1
Complications
Complications include infections, pneumothorax if poorly placed and/or managed, lung
injury after excessive suction, phrenic nerve irritation, Horner syndrome, or cardiac ar-
rhythmias. Disadvantages of thoracostomy tubes include prolonged surgical time, pro-
longed hospitalization and increased cost, and intense, regular maintenance required.1,9

Postoperative Care After Thoracic Surgeries

After thoracic surgery, the rabbit should receive supplemental oxygen. Radiographs
can be taken to assess the condition of the lung and to monitor the presence of air
in the thoracic cavity. Bupivacaine (2 mg/kg) can be diluted with saline and instilled
into the thoracic cavity every 8 hours through the chest drain for pain control. The
chest drain is used for removal of air and fluid after the surgery.65,66 Antibiotics, fluid
therapy, analgesia, and supportive feeding are recommended similarly to abdominal
surgeries.

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