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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).

THE ovariohysterectomy of cats is one of the most common thiopental sodium (Rhone-Merieaux) to effect and main-
surgical procedures in small animal practice. It is commonly tained with halothane (Rhodia Organique Fine) in 100 per
carried out either through a midline coeliotomy or through cent oxygen via an Ayer’s T-piece with Jackson-Rees modifi-
a flank laparotomy. In the UK, the flank approach is believed cation, with the cats breathing spontaneously. Carprofen (4
to be preferred, whereas the midline approach is said to mg/kg) (Rimadyl; Pfizer) was given subcutaneously immedi-
be preferred in the USA. There have been two small stud- ately after induction to provide analgesia, and a single dose
ies comparing these two surgical approaches (Hoque 1991, of clavulanate-potentiated amoxicillin (Synulox; Pfizer) was
Ghanawat and Mantri 1996), but to the authors’ knowledge given subcutantously to provide antimicrobial prophylaxis.
no substantial prospective studies have been made to com- Final year undergraduate veterinary students were allo-
pare them. cated to perform the surgery under the direct and continu-
At the University of Bristol Veterinary School, a spay-neu- ous supervision of faculty members or clinical training
ter clinic is a key part of the teaching of soft tissue surgery for scholars (residents). The students were allocated to each
final-year veterinary students, who perform the operations case before the approach was selected, to eliminate any bias.
under the direct supervision of veterinary surgeons, as per- Before performing the surgery, the students were directed
mitted by the Veterinary Surgeons Act. This study was in two to read an account of the standardised method to be used
parts; first a survey of UK veterinary practitioners was made for either a midline or a flank approach as appropriate. The
to establish their preferred approach to the ovariohysterec- number of operations already performed by the student as
tomy of cats, and secondly, a prospective study was carried primary surgeon by the flank and midline approaches was
out to test the hypothesis that there would be no significant ascertained.
differences between the two approaches, in terms, for exam- The cats were prepared routinely for aseptic surgery by
ple, of the duration of surgery or the incidence of surgical the relevant approach, and the urinary bladder was palpated
complications, when the operations were performed by vet- and emptied manually if necessary. The clinicians supervis-
erinary students being taught surgery. 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
MATERIALS AND METHODS throughout the procedure. The technique for the surgery was
Veterinary Record (2006) standardised as far as possible and was as follows.
159, 309-313 Survey of UK veterinary practitioners
A questionnaire was sent to 462 veterinary practices in the UK, Flank approach The cat was placed in right lateral recum-
R. J. Coe, MA, VetMB, 407 via a commercial mailing list and 55 via final year student bency and its legs were extended caudally with ties. The
CertSAS, MRCVS, extramural study placements. The practitioners were asked position for the incision was identified by visualising an
N. J. Grint, BVSc, CertVA, to give their preferred approach to the ovariohysterectomy equilateral triangle with vertices at the greater trochanter,
MRCVS, of cats (either flank or midline), and their preferred ligature the wing of the ilium and the centre point of the incision
M. S. Tivers, BVSc, materials for tying off the ovarian and cervical pedicles. (Feathers 1974); a sterile wire template 2·5 cm in length
MRCVS, was used to standardise the length of the incision. The skin,
A. Hotston Moore, MA, Clinical study subcutaneous fat, external aponeurosis, internal and trans-
VetMB, CertSAC, CertVR, Sixty-six cats from local animal welfare organisations under- verse abdominal obliques and peritoneum were incised in
CertSAS, MRCVS, went ovariohysterectomy before being rehomed. They were a dorsal to ventral direction to enter the peritoneal cavity
P. E. Holt, BVMS, PhD, more than six months and less than 10 years of age, healthy (time 1). In some cases, owing to difficulty in identifying
ILTM, DECVS CBiol, (American School of Anaesthesiologists grade 1), and were or exteriorising the genital tract, it was necessary to extend
FIBiol, FRCVS, not in oestrus, lactating or pregnant. the skin incision. The uterus was identified (time 2) and
University of Bristol, They were randomly assigned to either a flank or midline exteriorised. A window was made in the broad ligament/
Department of Clinical surgical approach by blocked randomisation. The anaesthetic mesovarium proximal to the ovary and the ovarian pedicle
Veterinary Science, protocol was identical for all of them. Acepromezine maleate was double clamped with Halstead ‘mosquito’ haemostats.
Langford House, (ACP Injection; Novartis Animal Health) at 0·1 mg/kg was The pedicle was ligated immediately below the haemostats
Langford, Bristol given as a preanaesthetic sedative by intramuscular injection; with 2 metric braided lactomer (Polysorb; US Surgical). The
BS40 5DU 30 minutes later anaesthesia was induced with intravenous pedicle was sectioned between the clamps and the stump

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was grasped with rat-toothed forceps for inspection after Start abdominal
the removal of the haemostat; after establishing that there Start of surgery Open peritoneum Find genital tract End of surgery
closure
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 I–P P–G G–S S–C
triple clamped and a further ligature was tied into the crush
of the lowest clamp. The uterine body was sectioned between FIG 1: Stages of the ovariohysterectomy procedure whose durations were recorded. I-P
the second and third clamps and the cervical stump was Time from first incision to entry into the peritoneal cavity, P-G Time from entry into the
inspected for haemorrhage (time 3). The internal and exter- peritoneal cavity to exteriorising genital tract, G-S Time from exteriorising genital tract to
nal muscle layers were closed together with 2 metric braided completion of removal of genital tract, S-C Time from completion of removal of genital
lactomer in a simple continuous pattern. The subcutaneous tract to completion of surgery
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; 0 and 100) were used to indicate the level of intervention
Ethicon) was used to appose the skin edges, and no skin during the procedure, and the student’s level of proficiency.
sutures were inserted. Stages during the procedure requiring particular interven-
tion, and any complications were also recorded.
Midline approach The cat was placed in dorsal recumbency.
Using the 2·5 cm wire template to define the length of the Owners’ responses The cats were discharged the morning
incision, the skin and subcutaneous fat were incised in the after the surgery. The owners were given a questionnaire and
midline midway between the umbilicus and the pubis, expos- asked to complete and return it seven days later. They were
ing the rectus abdominis muscles and linea alba. A midline asked to record any wound complications (discharge, exces-
or slightly paramedian incision was made through the linea sive licking, swelling or breakdown) and grade them as mild
alba or rectus abdominis muscles and parietal peritoneum to or severe. They were also asked to indicate on 100 mm VAS
enter the peritoneal cavity (time 1). scales (with no signs of pain and extreme discomfort, and
The procedure was then identical to that described for very satisfied and very dissatisfied, indicated by 0 and 100)
the flank approach. The uterus was identified (time 2) by the level of discomfort they felt their cat had experienced, and
repelling the intestine cranially and the bladder caudally and their degree of satisfaction with the appearance of the wound
grasped with atraumatic forceps. The incision was extended seven days after the surgery. They were also asked to indicate
if necessary. On completion of the ovariohysterectomy (time whether, given a free choice, they would prefer their cat to be
3) the incision in the abdominal wall was closed with 2 metric spayed by the flank or midline approach; the questionnaire
braided lactomer in a simple continuous pattern. The sub- contained basic information, in layman’s terms, of what was
cutaneous fat was closed with 2 metric braided lactomer in a involved in the two approaches.
simple continuous pattern. A subcuticular/intradermal con- The results were analysed by using SPSS 12.02. The data
tinuous suture of 2 metric poliglecaprone was used to appose were plotted as histograms to check for normality. For the
the skin edges and no skin sutures were inserted. purposes of correlation, the data for the total number of
spays performed before, and the total time taken to perform
Students’ response After the surgery the cats were moni- the ovariohysterectomy were transformed logarithmically
tored for 18 to 24 hours before being discharged from the to reduce their skewedness. Parametric data were com-
hospital. The tenderness of the wound and the level of seda- pared by using student’s t test. Non-parametric data were
tion of the cat were assessed regularly by a veterinary anaes- compared by the Mann-Whitney U-test (exact two-tailed).
thetist, and additional analgesia was provided if required. No Spearman’s rank coefficient was used to assess correlations.
further antimicrobial medication was administered. Categorical frequency data were tested by the chi-squared
After the surgery the students were asked to complete a test. Significance was set at the 5 per cent level.
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 RESULTS
indicated by 0 and 100 respectively), how difficult they felt
the surgery had been, how difficult it had been to identify Survey of UK veterinary practitioners
the uterus, how difficult it had been to exteriorise and ligate Of the 462 questionnaires, 183 were returned, a response rate
the ovaries, and how confident they would be to repeat the of 39·6 per cent.
procedure unassisted. In answer to the question about the approach used, two
During the surgery, the times in seconds from the first responses were unclear but 174 of the 181 other respondents
incision to each of the times referred to, were recorded and (96·1 per cent) indicated that they used the flank approach,
the times to complete the various stages of the procedure and the other seven that they used the midline approach.
were designated I to P, P to G, G to S, and S to C (Fig 1), indi- In answer to the question about ligature material four
cating respectively the time from the first incision to entering responses were unclear; of the other 179, seven (3·9 per cent)
the peritoneal cavity, the time from entering the peritoneal indicated that they used no ligature material, 159 (88·8 per
cavity to exteriorising the genital tract, the time from exte- cent) used chromic catgut, 12 (6·7 per cent) used polyglactin
riorising the genital tract to removing it completely, and the 910 (Vicryl; Ethicon) and one used polyglycolic acid (Dexon;
time from the removal of the genital tract to the completion US Surgical).
of the operation. The length of the incision at the end of the
surgery was also recorded. Clinical study
Thirty-four of the 66 cats underwent ovariohysterectomy by
Surgeons’ response The supervising surgeon also com- the flank approach, and 32 by the midline approach.
pleted a questionnaire; 100 mm VAS scales (with no interven- The mean (sd) final length of the midline incisions was
tion and continuous help, and very good and very poor, that 3·1 (0·6) cm and the mean final length of the flank incisions
is, higher scores indicating poorer performance, indicated by was 2·6 (0·2) cm, and significantly shorter (P=0·001).

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

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

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Papers & Articles

the midline approach, and the midline approach required a ACKNOWLEDGEMENTS

longer incision than the flank approach. However, there were
no significant differences in many other aspects of the pro- The authors thank the staff and students at the University of
cedures and either approach may be strongly supported or Bristol Veterinary Teaching Hospital for their assistance in
rejected as inappropriate by different surgeons. The results caring for the cats in this study. Thanks are also due to Dr T.
suggest that neither approach has any particular advantage Knowles for statistical assistance.
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
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Comparison of flank and midline approaches

to the ovariohysterectomy of cats
R. J. Coe, N. J. Grint, M. S. Tivers, A. Hotston Moore and P. E. Holt

Veterinary Record 2006 159: 309-313

doi: 10.1136/vr.159.10.309

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