CASE 6.  The Shih Tzu has a large belly button

"It is only six weeks old!" I said. "It is too young to go under the operating table!"  I pulled up the Shih Tzu puppy and looked at his belly. A large circular belly popped out from inside his abdomen. Could I say "no" to Mr Formicelli?

Mr Formicelli wanted to me to repair the large umbilical hernia in his Shih Tzu puppy. I was not keen to operate such a young puppy as his liver was not mature enough to metabolise the anaesthetic drugs and he might then die.

Mr Formicelli knew the risk of death. He could delay the surgery later but the hernia was really large. There were more benefits of an early operation. The puppy had more time to recover and would still be attractive to buyers even two to four weeks later. If he was operated at the 12th week as recommended by most veterinarians, he would be much bigger and less attractive to buyers at the 14th - 16th week. It took about 2 - 4 weeks to recover.

Should I operate or not?  The breeder was willing to risk his puppy. Was I willing to risk my professional reputation?  The death of a puppy stinks the reputation and I was not willing to do the surgery.

I should focus on the welfare of this puppy. The intestinal loops were visible under the thinned skin of the hernia causing much pain to the puppy (picture, right). Not as serious as another of Mr Formicelli's case, but delays would lead to the same situation.

"Is the puppy active and eating well for the past two days?" I asked Mr Formicelli. The puppy looked as plump as his two mates.  Maybe slightly smaller but not much difference yet. In another four weeks, he would lose out in weight gain as he would eat less as he feels the pain of the intestinal loops and liver lobes rubbing against the skin.

The puppy looked healthy. It should be a good anaesthetic patient. Now, when should the puppy be operated on?  Should it be eating 6 hours before surgery?

His belly button was more than 8 cm wide and I could see the intestinal loops impinging on the side. There was no protective muscle layer under the skin as in normal puppies.  Somehow, the skin looked paper-thin when there are no muscle and subcutaneous fat layers below it.

Mr Formicelli wanted the surgery to be done. He was a most successful dog breeder of years of experience.  He was successful in this business of live animals because his puppies grew up plump and  healthy. They were marketable by week 8 and look much bigger than their contemporaries at week ten.  Puppies at 8 weeks old fetch a premium and would be sold first compared to older ones. He would make more money to sustain his high cost of operations.

If the surgery enabled him to increase his revenue, just get a vet whom he could trust to do a good job.  No more waiting till week 12 as recommended by the professionals.   

Shih Tzus with large umbilical hernias are rarely seen in Singapore and I estimated one is seen in 1,000 puppies. A few of them have small umbilical hernais of less than 2.5 cm diameter. This condition seemed to be common in Shih Tzus compared to other breeds. 

"Umbilical hernias are present in brachycephalic breeds only," Mr Formicelli stated. "Pugs and Pekinese have such hernias. You don't see them in Golden Retrievers and German Shepherds."

The Shih Tzu has a shorter nose and he considered it brachycephalic which means "short head".  Actually, umbilical hernias are inherited. 

I took the puppy back to the surgery at 10 am. I operated on him at 4 pm so that his food would no longer be in his stomach. His belly defect stretched up to the liver lobes area. I could see the chocolate brown liver lobes under the hole. A lot of omental fat oozed out of the hole. Mr Formicelli really knew how to rear his puppies to make them fatter than the average ones you see in the pet shop.  I pushed back the fat, looked for the right and left muscle layers far away from the midline. I stitched the layers together. Around ten stitches were placed.  

It was nearly six o'clock when the surgery was completed. It was a minimal anaesthetic routine. When the puppy was moving, he was given more anaesthetic gas. This took a longer time to operate but was safer for the patient. 

I rushed him back to Mr Formicelli's kennels. Mr Formicelli had left the kennels.

He returned when he saw my car.  I made sure that he was not sleeping in a cold windy kennel and that Mr Formicelli gave him some food. The puppy was a bit groggy. He had cried a few minutes in the car. It must be the pain.  But now, he was all right. The next morning, he was eating.  Mr Formcelli felt that the wound would heal better without the bandage.  He had his magic special wound spray which reduced inflammation and killed viruses and bacteria. And it seemed to work very well as you can see from the picture of the 6-day operation puppy below. 

Six days later, his wound was healing well and he was as active as his two siblings. Mr Formicelli always recognised his puppies as he sees them every day 7 days a week.  He feeds them and nurses them when they fall sick.  Vets are meant only for Caesarean sections, vaccinations and surgeries.

The breeder could not differentiate him from the other two as he was not that thin or had poor weight gain.  He picked up the puppy on the extreme left of the 3-puppy picture below for me to check on its wound. No, it was the wrong party! 

Where's the real McCoy?  Would you be able to tell from the three puppies in the picture below?

The benefit of an early operation was that the puppy had not experienced the internal pain of the intestinal loops twisting and strangulating their blood supply. The puppy would not be able to talk, but it would eat less and lose out to its siblings in body weight gain.  It would become a runt as its growth rate dropped considerably. It would be very hard to sell it.

"What should I do with this 11-weekShih Tzu puppy with pink intestines about to burst out of his belly button?" I asked myself. "Should I just mind my own business and vaccinate the puppies as requested by Mr Formicelli and walk away?"

This stunted puppy would die in the next few days as the large intestinal loops get twisted further. The twists and turns of the loops strangulate the blood vessels. The intestinal cells die and the puppy dies in a very painful way.

The diagnosis was a massive inguinal hernia. The treatment was surgery to close up the hole in the belly. The puppy was in a poor bodily condition with all her puppy fat lost. Was it now too risky to operate on her?

Veterinary anaesthesia books mention that puppies less than 12 weeks of age are high risks, meaning they have a high rate of death from anaesthesia. The Shih Tzu was 11 weeks old.

The puppy had licked it a lot of time since three weeks of age when the hernia was detected. The weight of the abdominal organs and the friction on the cage floor thinned the skin considerably to less than a mm now. I could see the large intestinal loops under the skin. Any time, the skin would rupture and the Shih Tzu, now skin and bones would die painfully.  

She was smallest of the four Shih Tzu puppies when I vaccinated her 3 weeks ago. I remember her very well because she had a large umbilical hernia of 8 cm in diameter, a size bigger than the width of two adult fingers.

The assistant was very good at puppy care. He had seen numerous umbilical hernias in puppies and would have informed Mr Formicelli of this unusually large defect. He would have encountered puppies with small umbilical hernias of around 1.5 cm in diameter and surgery was not urgent in such cases. 

3 weeks ago, I said to Mr Formicelli's assistant during vaccination: "This 8-week-old Shih Tzu needs surgery to repair the big gap in the muscle layer of the belly region. Do ask Mr Formicelli for permission. It will be hard to sell this puppy with such a large defect in her muscles."

The assistant did not get back to me. I phoned him a week later and he said that Mr Formicelli had not decided on the surgery. "Was it the $200 cost of general anaesthesia and surgery?" I asked him but he did not say anything. Silence is golden.

Many dog breeders and pet shop owners had to cut operating costs in this severe economic downturn attributed to SARS (severe acute respiratory syndrome) and I could understand that. But $200 should not be a big problem with Mr Formicelli who was a very successful operator, I thought. Yet, every dollar saved is a dollar earned. After all, Singapore Airlines reputedly the world's most successful airline  over the past twenty years, was cutting salaries of pilots and retrenching staff.

In retrospect, I should have phoned Mr Formicelli 3 weeks ago to warn him about the impending death but that would be tantamount to touting. Mr Formicelli might feel offended although he would be too polite to tell me off. 

Most important of all, there was no guarantee that an 8-week-old puppy would survive the general anaesthesia and post-operation days too.

3 weeks passed and now I could not believe my eyes.  Her inflamed hernia skin was stretched a lot, weighed down by the internal organs. Just like pregnant women with stretch marks, but this was much worse. The herniated area was very thin now, due to continual licking by the puppy to relieve the pain and discomfort. The skin became inflamed. I could even see that a loop of the large intestine is inflamed, due to the friction between it and the floor.

 The large intestinal loops imprinted onto the skin making a U-shaped stamp. A triangular lump above the U-shape could be the lobe of a liver. In a few days, the skin would rupture as it became thinner than paper. The intestines and liver lobes fall out of the body. A very painful death, just like being stabbed in the abdomen.

Somehow, it was not right to abandon this Shih Tzu which was more lively and fatter three weeks ago. Is there a way to help this Shih Tzu? What could I do? Why should I be bothered?

This hernia could be repaired but would the puppy survive the general anaesthesia and post-operation surgery?

The chances were  slim. Most veterinary surgeons would like to anesthesize puppies less than three months old. They are high anaesthetic risks. The surgeon gets a bad reputation - "the puppy died when the vet operated on it" would be spread by word of mouth and via the internet.

It was so easy to walk out of this Shih Tzu puppy. Mr Formicelli was not at the shop. There was one foolhardy option.  

"Will you sell the puppy to me for $50?" I asked Mr Formicelli's mother. A silver-haired slim woman in her seventies, she was grooming a poodle. She did not need to work at all and could enjoy her mahjong sessions and shopping in Singapore, a city known to have more shopping malls than New York.

She could afford the fanciful coiffured hair style, wavy and permed like other Singapore's tais tais (ladies with wealth), but she simply had short hair with two pony tails on either side tied by rubber bands.

"$200," she replied in a serious tone. Her sun-tanned face revealed no emotion.   Nobody would purchase this sickly puppy.  Therefore, it had zero value. This would be the time to back out of the offer. If she had said yes, I could not demur since I had asked her.

"This puppy needs an operation," I murmured.

"$100," she said without looking up as she clipped the puffed up head hair of the white toy poodle for its Singapore Kennel Club dog competition.  Now, I know why Mr Formicelli is so successful in his canine pet shop business. He had good training from his mum. If she could sell this puppy for $100, she could sell ice to Eskimos.

"The operation to repair the hernia will cost more than $100," I replied. I had blown away a second chance to back out. I had not done a veterinary examination of the Shih Tzu puppy. I had not even checked whether she had a normal heart and other hereditary defects.  It was rash to offer to buy a such a puppy.

"$50" Mr Formicelli's mother said.  Better to get $50 than pay more for an operation for a sickly puppy. She knew about the fragility of runts, of stunted puppies in her four decades of pig farming which was extinguished by the Singapore Government's policy later.  This puppy would not survive for the next few days. Now, I could not back out of her offer.  

I took the puppy back to the surgery and put her in a cage for observation for one day. She did bark a few times for attention. What a strong girl! But she was nibbling a bit of dry dog food just to survive. Like an anorexia nervosa teenaged girl who is afraid of being fat. I had better operate on day two as the intestinal loops turned fiery red under the skin.  The intestinal loops could be twisting and the blood vessels would be partially strangulated.

 

Her rectal temperature was 37.7 degrees Celsius pre-operation. Normal temperatures are around 38.5  - 39.0 degrees for a puppy. She was going into hypothermia. I gave her a dextrose drip prior to anaesthesia to increase her chances of survival.

I covered the puppy with a face mask. She struggled weakly to avoid breathing the gas. Would her heart fail to beat in the struggle?

When she was just in deep anaesthesia stage 10 minutes later, I pulled her tongue and inserted a 3/0 endotracheal tube (breathing tube) inserted into the windpipe.

I incised the thin skin. A big operation wound from her navel to her sternum. Now, the big 8-cm hole revealed the light brown liver lobes and intestines.

Where were the left and right abdominal muscle layers needed to stitch up to cover this gap?  The paper-thin skin was just holding the internal organs.

Nurse Ann furrowed her forehead: "The puppy is moving her front legs." The light brown liver lobes and the large intestinal loops spilled out of the incision." 

"Increase the anaesthetic by 0.5%" I said to Nurse Ann. Would the puppy die? What would be the safest dose of gas? There was no fixed percentage for high- risk puppies but normal adult dogs could be maintained on 2.0 - 2.5% of ghte gaseous anaesthetic. I had to be observant.

I needed to operate fast. But where were the two left and right abdominal muscle layers to stitch and close up the wound? In small hernias, I could see the muscles as the gap was small.

This was a 8 cm diameter hole protected by the skin only. Were there any muscles in the first place?  I loosened the skin layer. I lifted the skin up with the forceps. The muscles had retracted far away, nearer to the top of the rib cage. I snipped off the excess skin stretched paper thin by the herniated intestines. The left and right layers of the skin were then stitched up.

The puppy was kept warm in a cage after the end of the operation. 12 hours later, she could not sit up. Fainted.   She was hypothermic again and laid down on her side. Would she survive? She was forced fed an egg.    
 
24 hours later, she could eat on her own. She sat on her sternum like all puppies. But she was not eating much. I checked her gums. They were pale pink. The tongue was also pale pink. She coughed occasionally. A dry hacking cough, just like the kennel cough common in puppies kept at pet shops. No fever.

She screamed when I injected antibiotics and dextrose saline under her skin. Would she survive the kennel cough infection? I force fed her another egg and went to see Mr Formicelli's mother.  She must have thought that I wanted to return the puppy and wanting my money back. Like so many buyers who became unhappy after purchasing unhealthy puppies from pet shops.

"What brand of puppy food did you feed the Shih Tzu?" I asked as I showed her a sample of what I fed to the puppy. The puppy was not eating much and it might be because I fed her another brand of dry feed.

"That's brand A," she said instantly as she recognised the greenish brown triangular  pellets.

"I feed the Shih Tzu brand B." She presented me a small plastic container of small globular chocolate brown pellets. She stopped her sales girl who was selling me a full bag.  Then she sealed a small plastic bag of oats for this Shih Tzu. I thanked her.

36 hours later, the Shih Tzu had better appetite and passed a larger amount of greenish stools. She barked strongly and her tongue was a better colour of pink. That was a good indicator of good health. This was a real hardy Shih Tzu. If she live for the next seven days, she should be able to live a normal life.

Why did Mr Formicelli not operate this puppy earlier? A stitch in time saves nine. I just had to know. I mobile phoned him. "The puppy had fever the past week and was treated," Mr Formicelli explained. "I would send her for surgery when she had fully recovered in two weeks' time."

I told him that her mum had sold the puppy to me. Breeders lose their respect for vets who tout for their business patronage. Respect does not pay the bills though as the cost of doing business keeps going up in Singapore as the bureaucrats think of ways to  charge fees for new and various licensing regulations to justify their bonuses and existence.    

There are many canine problems in the pet shop and breeding farms to treat, but the cost-conscious operators would rather self-treat.  If they could operate on hernias, they would do them.

In this Shih Tzu, an early operation at four weeks of age would be best. If she survived the anaesthesia,  she would have put on weight and be valued at eight hundred dollars at 3 months of age.  The anaesthetic time would  be much shorter. This was a case of a stitch in time saves nine.

There was a possibility of Mr Formicelli spending $200 and losing a puppy during or after anaesthesia. If the puppy was not operated and died, it would just be one of those losses in the dog breeding business.  It was pragmatic of him not to throw good money after bad as there was no guarantee that the puppy would not die on the operating table. 

The puppy was weak during the 3 days after surgery. Her tongue was pale. She was hand fed and given antibiotics and fluid therapy. In the second week after surgery, she put on weight. Her incisor teeth had not erupted yet as Shih Tzus take a longer time. She was a very small sized puppy now.

It took another 2 months of nursing before this Shih Tzu put on weight as normal puppies do. Eat, sleep and play.  Small circular patches of hair loss appeared under her armpits and in her groin.
It was a fungal infection. Nurse Ann shampooed her with the anti-fungal wash. More circles appeared on her elbow and body. The washing could spread more fungal spores.   I gave her anti-ringworm medication for twenty days as well as the shampoo. She recovered and found a good home.

With extension education and visits, breeders are informed on the risks and benefits of hernia repair.  Small hernias of less than 2.5 cm may not need surgery, but large ones are best repaired as the risk of incarceration of the intestines and death due to blood supply strangulation is greater. 
 

BREEDERS:  BE KIND TO PUPPIES  - A  puppy's life is precious. 
The puppy can't talk but it feels the pain of the intestinal loops and liver lobes scraping the skin which becomes thinner.  The puppy eats less and becomes a dwarf by week 12 and is unsellable.

In 99% of the surgical cases, the normal puppy does not die from the anaesthesia or surgery.  Large hernias over 1-2 cm are best repaired as some of them do split to become bigger.  There is the possibility of the intestines stuck inside the hernia being twisted and the puppy dying consequently, especially if the hernia is large.    

Toa Payoh Vets' recommended time
to repair the large umbilical hernia is at 6 weeks of age. Some puppies do not grow well if the hernia is not repaired. However, general anaesthesia in puppies younger than 12 weeks old is reported to be high risk.  Consult your vet for his or her advices as the anaesthesia is high risk. Work closely and happily with your own vet in the best interest of your pet.   Copyright © Asiahomes Internet, 2004. All rights reserved. Revised: March 18, 2005  

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