A Lively Liver Tango

Hero was a very handsome German Shepherd and at seven years of age, he visited our hospital every six months for routine preventive care. He was current on heartworm and flea prevention, was well trained, and had a surgery as a four year old for a ruptured ACL ligament in his right knee. His annual blood work was always unremarkable. He is a charming dog that behaves beautifully and handles life with grace. Today, though, Hero wasn’t feeling so great. His head was dropped down, he didn’t wag his tail when the nurses chattered at him, and he walked with an odd, hitching gait. Mr. and Mrs. Davis were worried about Hero. He was fine the evening before, playing with the neighbors dog, ate his normal evening meal, and went to bed. He seemed a bit restless overnight and this morning her refused his breakfast. Mrs. Davis was adamant that something was wrong with Hero, and Mr. Davis called off work to bring Hero to the hospital. I rubbed Hero’s ears and he gazed into my eyes with the most piteous look. His eyes were a bit sunken and his gums were sticky to the touch, indications of dehydration. His gums were darker than usual, a sign of decreased blood flow. Hero’s heart was beating a bit too fast. His joints had normal range of motion with no pain on palpation and a rectal exam was unremarkable. As I pressed my fingers into his abdomen I was surprised to feel a large mass, just before Hero cried out. He tolerated me pressing into his lower abdomen; his intestines and bladder felt normal.

I relayed my physical examination findings to Mr. and Mrs. Davis and stressed that we needed to do further diagnostics, but Hero might need emergency surgery. The Davises were visibly upset and Mr. Davis said “Doc, we don’t have much money.” I felt dread welling up in my stomach; finances and hearts often diverge in veterinary medicine. I took a deep breath and explained that we needed to start with blood work and IV fluids. I provided an estimate and asked them to approve the initial costs so that we could start helping Hero feel better. I promised that we would help them figure out finances as soon as we had Hero’s blood work and fluids started. While a nurse drew blood and placed an IV catheter, I considered the possibilities. The possibilities in an adult German Shepherd were numerous; gastric bloat with possible torsion, toxin ingestion, pancreatitis, foreign body, gall bladder disease, liver disease, and diaphragmatic hernia. After giving Hero an injection of pain medications and while we waited for the results of Hero’s blood work, I explained the possibilities and talked about funding. The Davises applied for Care Credit, a deferred interest rate credit card for medical care. I’m not a fan of deferred interest rate cards because of the high interest rate that takes effect if the balance isn’t paid in full by the end of the interest-free term, but often don’t have better options for owners. The Davis’s qualified for Care Credit but were very concerned about taking on such debt. We talked about Hero and how everyone in the neighborhood knows Hero. It’s hard, as a veterinarian, to talk to owners about money, and it is hard for folks like the Davises to ask for financial help. Sometimes, when the stakes are high, we do things that aren’t so comfortable. We encouraged the Davises to visit their neighbors, share their story, and see if anyone was able to help out. We also provided the Davises with a list of charitable organizations that might be able to provide some assistance.

Hero’s blood work revealed mild elevations in liver enzymes and increases in white blood cells. We also took radiographs (x-rays) of Hero’s abdomen, which showed mild gas distension in Hero’s stomach but no evidence of gastric dilation volvulus or bloat, where the stomach swells with air and twists upon itself damaging organs and cutting off blood flow. The lines of the tissues in the radiograph were blurred by excess fluid in Hero’s abdomen. The lines around Hero’s liver were blurred and his liver seemed enlarged. We discussed emergency surgery, the risks to Hero, and the possibility of not being able to solve his condition. The Davises agreed to surgery and headed home to make phone calls and try to raise funds. We prepped Hero for surgery by shaving his entire belly from sternum to pubic bone then scrubbed him for surgery. This type of surgery is called an exploratory; we don’t actually know what we will find when we enter the abdomen, but we hope for answers and wish for cures. Just before we opened Hero’s abdomen up, we ran antibiotics into his blood stream to help reduce the risk of infection.

Long incisions aren’t as simple as they appear; I braced my left hand against Hero’s sternum (covered by a sterile drape) and placed my finger and thumb on either side of the midline of his belly to draw the skin tight towards the sternum and away from the midline. I gripped the scalpel in my right hand and extended my index finger over the top to rest on the back of the blade, then placed it between my left finger and thumb and drew back with mild pressure, opening the skin from sternum to pelvic bone in a single long slice. The skin pulled slightly away from the incision and subcutaneous tissue, mostly fat, peeked from beneath. With the scalpel set aside, I used a pair of forceps that appear similar to large tweezers to draw the subcutaneous tissue up and cut it away from the body wall beneath the skin with a pair of surgical scissors.

The motion is similar to trimming fat from a turkey while skinning it for a holiday dinner. This leaves the linea alba, a fibrous connective tissue that runs between the sets of abdominal muscles, exposed. Cutting through the linea alba leaves those muscles intact and gives us access to the peritoneal, or abdominal, cavity. To cut into the peritoneal cavity, we pull up on the linea alba near the pubic bone with the forceps and, turning our scalpel blade upwards, stab into the linea alba while trying to avoid damaging any organs. Some doctors will use the blade then to cut the linea alba from pubic bone to sternum, but I prefer to replace the blade with surgical scissors called Metzenbaums. I can actually use the scissors to draw the linea alba up and free from the underlying organs then cut, similar to slicing through wrapping paper.

When I performed my first abdominal surgery, I expected the variations in color and the movements of organs, but I was surprised by the heat of the body. Hero’s internal organs appeared darkened, almost as if I were wearing sunglasses under the bright surgical lights. These organs contrasted with bright red blood that was oozing from the top of the liver. The blood pooled around Hero’s intestines, which were stiller than usual. Dogs have seven liver lobes resting above and draping around the stomach and gall bladder. Hero’s left most liver lobe, the left lateral lobe, was large, dark, and the surface was slowly oozing blood. As I felt around the top edge of the left lateral liver lobe where my fingers encountered something that felt like a twisted cord; Hero’s liver had twisted on its own vessel. I resisted the urge to untwist the liver lobe as doing so would release toxins from the dying tissue of his liver lobe back into his blood stream, which would send him into shock. Hero’s liver had danced a tango and twisted about in his abdomen.

My fingers tucked thick suture material around the vessels and tissues where the torsion originated, far into the abdominal cavity in a space I couldn’t see, where the surgery light wouldn’t reach. My fingers rotated the line of the suture, tucking the right line beneath the left, then the left beneath the right, repeating the pattern several more times and wrapping the line across my fingers and drawing as tight as I could between each tuck. This causes the suture to ratchet down and the layers of tucks lock the first knot in place to form a ligature around the tissues. After carefully placing another ligature above the first, I slid a hemostat, or clamp, closer to the damaged liver lobe. I then laid the closest ligature over my left index finger and the hemostat over my middle finger with my thumb resting in the space in between. This is the space I would cut to remove the twisted liver lobe. I took a deep breath and tucked the scalpel blade into my right palm with the blade placed between my index and middle finger tips to cover the sharp edge to prevent stabbing important, healthy liver tissue. When I had the tips of my middle fingers touching, I used my right index finger to gently slide the blade across the vessels. As the vessels separated between the fingers of my left hand, I gently grasped the damaged tissue and lifted the lobe from Hero’s body. I carefully dropped the liver into a sterile dish and set the scalpel aside. Gently grasping the sides of Hero’s abdominal cavity, I angled his torso to shed more light on the source of the problem. To my relief, the ligatures were holding.

Next I carefully searched for other signs of bleeding around Hero’s liver, then traced his gastrointestinal system; stomach healthy and in its proper place, pancreas and spleen looking lively, intestines laying in their proper place, and kidneys still resting in the back of Hero’s body. I reviewed Hero’s response to anesthesia; his heart was doing well, blood oxygenated, and blood pressure improving. I carefully tacked Hero’s stomach to the left side of his abdomen, in a procedure called a gastropexy, to help prevent it from twisting like his liver had. I then started the long process of closing Hero’s abdomen up, slowly pinning the sides together by using single sutures starting in the middle. When the edges were held relatively close together, I threaded the suture through each side of the linea alba in an easy simple pattern. Once the linea alba was secured, I closed the subcutaneous and subcuticular tissues in a similar manner, then placed staples along the entire length of the incision.

We brought Hero up from anesthesia and he nuzzled our faces before we could even remove the tube that delivered oxygen from his throat. After a quick call to his parents, we examined the liver, then made long even slices to help the preservative seep into the tissue. The liver was placed in a jar of preservative and sent to a lab for a careful analysis. While I was pretty sure the liver lobe had twisted on itself, we didn’t know why, and we couldn’t absolutely rule out a cancer in that lobe. The Davises were thrilled to see a happy Hero that evening and reported that their friends and community had come together to support him. While they had asked friends to lend them money, many gave them smaller gifts and spread the word. As neighbors and other associates found out that the gorgeous Hero was in need of his own heroes, contributions flowed in. The Davises found support for their charming dog, and Hero’s bills were paid more quickly than expected. Two weeks later the tissue came back as not cancerous and Hero’s staples came out. His parents visit our hospital regularly, and Hero continues to amaze all of us.

1 Comment

  1. Thank you for your detailed insight – all things medical, financial and social. A huge responsibility lay in your hands. Thank you for sharing

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