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PRINCIPLES OF REPTILE SURGERY R. Avery Bennett, DVM, MS, Diplomate ACVS University of Florida, College of Veterinary Medicine, Gainesville, FL ANATOMY The anatomy of reptiles varies among orders, families, and species. A knowledge of the basic features of reptilian anatomy is therefore vital to surgeons. Cardiovascular System - Chelonians and squamates are considered to have a 3 chambered heart because the ventricular septum is incomplete. Reptiles have 2 aortic arches that spiral on each other. The left aortic arch receives part of its blood from the oxygen-poor right ventricle and the right aortic arch mainly receives oxygenated blood from the left ventricle. Crocodilians are considered to have a 4 chambered heart, although the foramen of Panizza is present within the septum and allows some mixing of ventricular blood. Reptiles have a renal portal system that receives venous blood from the pelvis, the rear legs, and the caudal part of the abdomen. The system carries blood to the renal arterial circulation. Digestive System - Except for most snakes, reptiles have a cecum. The stomach of crocodilians has 2 compartments. The first is very muscular and frequently contains stones. The second is similar to the glandular stomach of mammals. All reptiles have a gall bladder. The liver of many reptiles contains melanin and can have black spots or streaks. Reptiles generally have little subcutaneous fat and store fat in discrete masses (called fat bodies) in the caudal abdomen. Urinary System - The metanephric kidneys of reptiles are lobulated. One or more renal arteries can be present to receive blood from the renal portal system. The nitrogenous wastes of reptiles are in the form of ammonia, urea, uric acid, or a combination of these. Crocodilians, snakes, and some lizards do not have a urinary bladder. In chelonians and those lizards with a bladder, it is connected to the cloaca by a short urethra. Urine passes into the cloaca and then into the urinary bladder, if present, or into the distal colon where water resorption occurs. Cloaca - The cloaca typically consists of 3 chambers. The coprodeum is the most cranial and receives fecal material and urinary wastes. The urodeum is the middle section and receives genital secretions and urinary wastes from the urogenital ducts. The caudal proctodeum acts as a reservoir for fecal and urinary wastes before they are excreted. This is also the location of the openings of the musk glands. Integument - The skin of reptiles is dry and virtually devoid of glands. Many lizards have femoral glands, which open on the medial aspects of the thighs. Crocodilians have a pair of scent glands in the medial aspects of the lower jaw and another pair within the cloaca. In proposing sites for incisions, these glandular areas should be avoided. The skin of most reptiles is made up of scales and scutes. Soft shelled turtles and some lizards do not have scales but have a leathery, smooth skin. Crocodilians and some lizards have calcific plates, called osteoderms, located within the dermis designed for protection. Incisions can usually be made between osteoderms. The shells of chelonians are composed of bony dermal plates covered with keratinized epidermal shields. The carapace contains 10 fused thoracic, lumbar, and sacral vertebrae as well as the ribs. The plastron and the carapace are joined at the so-called bridge.

Histologically, the epidermis is composed of 3 layers. The outer stratum corneum is heavily keratinized, acellular, and has a serrated surface. The middle intermediate zone is composed of daughter cells of the stratum germinativum in various stages of differentiation. These 3 layers are present during the skin's resting phase. As ecdysis begins, the cells of the stratum germinativum undergo synchronous mitosis to form a new intermediate zone and stratum corneum under the old generation. The action of enzymes breaks down the cells of the base of the old intermediate zone, and the subsequent influx of lymph causes separation between the old intermediate zone and the new stratum corneum. Blood vessels and sinuses in the head become engorged and cause it to swell. The old skin splits and ecdysis is completed by the animal rubbing off the old skin. In squamates, this process occurs simultaneously over the entire body. In chelonians and crocodilians, proliferation and keratinization are continuous and shedding occurs only at the flexible regions of the body. This produces growth rings between these scales as they grow and the previous, smaller layers are not lost. The frequency of ecdysis is proportional to the growth and metabolic rates of the animal. Age, environmental temperature, availability of food, and space can influence the frequency. In squamates, the cells of the epidermis are mitotically active only during ecdysis. WOUND HEALING Skin wounds of reptiles undergo phases of healing similar to those observed in mammals. Wounds strengthen slowly and skin sutures are generally not removed until at least 4-6 wk. Many factors influence wound healing in reptiles. Maintenance of the environmental temperature at the high end of the optimum range promotes healing. In snakes, cranial to caudal wounds heal faster than dorsal to ventral wounds. Open wounds heal well by second intention with a low incidence of infection. PATIENT PREPARATION Ideally, laboratory data should be obtained before induction of anesthesia. Because of the small size of many patients and the inaccessibility of most peripheral veins, blood samples are often difficult to obtain. Environmental conditions, time of day, and laboratory variations can influence blood cell counts and biochemistry data making interpretation difficult. If blood samples can be obtained repeatedly, trends provide valuable information. The hydration and nutritional status of patients is assessed as it would be for mammalian patients. Balanced electrolyte solutions can be given IV or IP. Reptiles are susceptible to a variety of microbial infections. It is imperative that aseptic technique be used. Many cutaneous infections result in septicemia and lead to visceral granuloma formation. Perioperative antibiotic therapy is more appropriate if intraoperative contamination is anticipated. It has been suggested that amikacin be used in snakes at a loading dose of 5 mg/kg followed by 2.5 mg/kg every 72 hr. Gentamicin at 2.5 mg/kg every 72 hr maintains adequate therapeutic plasma concentrations in gopher snakes and red eared slider turtles. In view of the long plasma half life of these antibiotics, one dose prior to surgery should provide perioperative coverage. Patient positioning is a challenge especially for legless and small reptiles. For snakes, a sterile stockinette can be rolled over the surgically prepared patient. The snake can then be placed on a sterile drape providing an aseptic field. The dome shape of the carapace of chelonians makes it difficult to position a patient in dorsal recumbency. A towel can be rolled into a ring such that the carapace will fit into the ring and prevent the patient from rolling. Clear plastic adhesive drapes are very useful in reptiles. The entire patient remains visible under the sterile drape allowing for proper

anesthetic monitoring. Sterile spray adhesives can also be used to allow paper or cloth drapes to stick to the patient avoiding the use of towel clamps. INSTRUMENTATION With a few exceptions, the instruments needed for surgery on reptiles are found in a general surgical pack. Most abscesses in reptiles contain caseous, inspissated pus. Dental curettes and cerumen loops help in removing this material. Eyelid retractors work well as abdominal retractors for small patients. With most chelonians, some type of saw or drill is needed to approach the coelomic cavity and a restorative material should be available for repair of shell defects and celiotomies. The edges of incised reptilian skin have a tendency to invert. An everting suture pattern, such as a horizontal or vertical mattress, achieves accurate skin edge apposition. The relatively tough reptile skin and scales help prevent sutures from tearing through. The break down of absorbable materials appears to be prolonged in reptiles and if used in the skin, removal is recommended after the incision has healed. Chromic catgut was still present in a rhinoceros viper 12 weeks after the material was used in the pleuroperitoneum and SQ tissue. It appears to be best to use materials which are absorbed by hydrolysis rather than proteolysis in reptiles. In squamates, suture removal should be performed after the ecdysis subsequent to surgery. The shed skin usually sticks in the sutured area for several ecdyses postoperatively, but can be gently peeled away. POSTOPERATIVE CARE Anesthetic recovery in reptiles can be prolonged and difficult to monitor. Increasing the environmental temperature to the upper end of the optimal range (3036o C) will increase the rate of metabolism of anesthetic agents. Once the patient is awake and responsive, it should be placed in a warm, dark, quiet place to complete its recovery. Clean paper should be provided in the recovery area to prevent contamination. Hibernation should be delayed for at least 6 mo as it delays healing. Swimming should be prevented for 7-14 days after surgery. Fluid therapy may be administered IV or IP as needed to maintain hydration. Many reptiles become anorectic after surgery. Force feeding or tube feeding might be necessary. CELIOTOMY Indications for celiotomy in reptiles include egg binding, egg peritonitis, gastrointestinal obstruction, ovariohysterectomy, colopexy for colon prolapse, cystotomy for calculi, and exploration for biopsy. The technique varies depending on the family to which the patient belongs. In snakes, abdominal incisions can be made at the lateral margin of the scutes or between the first 2 rows of lateral scales. Incisions should be made between rather than through scales if possible. The tips of the ribs should be avoided at the junction of the scutes and scales. The lateral approach is generally preferred over a ventral midline approach as it is easier to keep clean. The suture line is not in direct contact with the substrate and is not stressed by rectilinear motion. Three layers are encountered: skin, muscle, and pleuroperitoneum. When separate layers are not identifiable, a single-layer closure is adequate. Paralumbar and midline incisions have been recommended for approaching the coelomic cavity of lizards and crocodilians. The ventral abdominal vein is a very large vein located inside the body wall on the ventral midline. It should be avoided during celiotomy by using a paramedian approach. In chelonians with a small plastron, the majority of abdominal structures can be approached through an incision between the plastron and the femur in the flank region.

In other chelonians it is necessary to perform an osteotomy of the plastron. The pelvic bones should be avoided and can be identified using radiography. Usually the femoral and abdominal shields are osteotomized for the approach. A high-speed burr or an orthopedic saw is used to cut the plastron. Irrigation is used to dissipate heat and to remove dust. The bone is elevated from the underlying abdominal musculature using a periosteal elevator. The incision into the abdominal wall can be performed using a flap technique or a ventral midline incision. There are venous sinuses on each side of the midline approximately midway between the midline and the bridge. These sinuses should be avoided but can be ligated if necessary. The bone is replaced using restorative material as is described below. SHELL FRACTURE Small defects or cracks in the shell of chelonians can be maintained in reduction with wires, external bandages, or acrylic materials. Acrylic materials, such as those used for hoof reconstruction and dental repairs, can be used to hold fragments in apposition. The fracture should be maintained in reduction for 3-7 days without exposure to water so that a seal can form. The fixation should not be removed until there is radiographic evidence of union. Large defects should be repaired using prostheses. Various restorative materials have been used, including hoof or dental acrylics, boat or autobody fiberglass, and epoxy resin. Patches of fiberglass cloth can be autoclaved. The fiberglass provides a matrix to enable the resin to bridge the defect. The patch should be large enough to extend beyond the margin of the defect. The shell should be cleaned with acetone, ether, or similar degreaser. During application, care must be taken to keep epoxy from the edge of the defect as its presence will delay healing. The fiberglass patch is stretched over the defect and held in place, allowing the resin to penetrate the cloth and bond to the shell surface. When this layer has cured, a light coat of epoxy is applied to the fiberglass cloth over the defect. After this layer has cured, several more thin layers of epoxy should be applied to strengthen and seal the defect. If a large fragment is to be replaced, as in the case of closing a celiotomy, the piece should be bonded to the center of the cloth patch with epoxy before the patch is applied to the defect. Healing of bone in reptiles takes at least 6-18 mo. In growing chelonians, the patch should be removed from the growth rings after healing is complete to allow the shell to continue to grow. Epoxy dust can be toxic and carcinogenic to humans. Copious irrigation should be used to prevent aerosolization, and a face mask should be worn. DYSTOCIA Clinical signs of dystocia include anorexia, regurgitation, straining, cloacal discharge that is often malodorous, paresis, respiratory distress, and edema of the cranial extremities. Noninvasive procedures should be attempted before surgical intervention. Intramuscular oxytocin at 1-10 IU/kg and IM or SQ 1% calcium borogluconate at 10 ml/kg have been successful to relieve dystocia when manipulation was not. In species that produce soft and leathery eggs, percutaneous ovocentesis can collapse the eggs and allow them to pass more easily. Salpingotomy is indicated if noninvasive techniques fail or if there is radiographic evidence that natural passage is not possible. In snakes, it might be necessary to make more than one incision to access all eggs or fetuses. The incision in the salpinx and uterus should be repaired with an inverting suture pattern of an absorbable material. Salpingohysterectomy should be considered if dystocia recurs, if the patient is not being maintained for breeding purposes, or if bacterial salpingitis is present. The ovaries of many reptiles are not pedunculated making them difficult to remove. Removal of the ovaries may not

be necessary. During salpingohysterectomy the oviduct should be pulled free from the ovary and the uterus should be ligated as close to the cloaca as possible. The presence of egg yolk within the coelomic cavity produces severe inflammation. Fibrin deposition and serosal thickening are typical. Surgical removal of the yolk material and lavage are indicated, however, the prognosis in such cases is grave. CLOACAL ORGAN PROLAPSE The cloaca has openings from the colon, uterus, urinary bladder, and reproductive tract. Ureteral prolapse has not been reported in reptiles. Squamates have paired copulatory organs called hemipenes which lie inverted within the tail. Chelonians have a single penis which is everted during copulation. Although prolapse of the penis or hemipenes has been reported as a sequel to constipation and neurological dysfunction, it is most frequently the result of infection, forced separation during copulation, or swelling secondary to probing for sex determination. The organ should be cleaned, gently lubricated and replaced. A purse string suture is placed in the cloaca tight enough to prevent prolapse but to allow voiding. The suture should be left in place for 3-4 weeks. If the prolapse cannot be reduced, the cloacal opening can be enlarged by incision. Surgery is indicated in cases in which the organ is severely swollen and damaged. Amputation is performed after mattress sutures are placed at the base of the organ to prevent hemorrhage. Snakes and lizards with one hemipenis are considered fertile. Prolapse of the uterus is rare but does occur. Replacement should be attempted. If reduction is not possible, celiotomy and salpingohysterectomy should be considered. Colon prolapse can result from straining because of constipation or bacterial or parasitic enteritis. Conservative management should be attempted before surgical therapy. Often colon prolapse is reducible and successfully managed by treating the primary cause while maintaining a purse-string suture in the cloaca. Frequently the venous return from the prolapsed colon is severely compromised and it becomes engorged and friable. Celiotomy and colopexy are recommended in such cases. An area of healthy colon should be selected and sutured to the body wall. If the colon is severely compromised, it can be resected and anastomosis can be performed. GASTROINTESTINAL PROCEDURES Principles of gastrointestinal surgery in reptiles are similar to those in mammals. The intestines of most reptiles are thin walled, and the use of fine sutures and an atraumatic needle is recommended. Such sutures as polydioxanone are strong and maintain their tensile strength for several months in mammals which can be advantageous in slow healing reptiles. If the affected section cannot be adequately exteriorized, it should be well packed off before enterotomy. Copious coelomic lavage with saline should be performed before closure. CYSTOTOMY Cystic calculi can occur in those reptiles with a bladder but desert tortoises seem to have the highest incidence. Clinical signs associated with cystic calculi are nonspecific and include anorexia, lethargy, and depression. The urinary bladder is generally very mobile within the coelomic cavity and is easily isolated during surgery. A 2 layer closure using an inverting pattern of absorbable suture is preferred. FRACTURE REPAIR

General principles of fracture management - anatomic reduction and stable fixation - apply to reptiles. Reptilian bones apparently heal much slower than mammalian bones requiring at least 6-18 mo for complete healing. Pathologic fractures resulting from nutritional secondary hyperparathyroidism are also common. These fractures are difficult to stabilize with internal fixation because the bone is too soft to hold implants. It is best to correct the metabolic cause of the osteomalacia and treat the fracture with external coaptation splints. 1. Bennett, RA. 1989. Reptilian surgery, parts I and II. Comp Cont Ed Pract Vet, vol 11 (1 & 2).