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🐾 Cats aur Dogs mein Leg Amputation (Limb Amputation)

— A to Z Complete Veterinary Guide for Vet Students —

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📌 1. DEFINITION — Amputation Kya Hai?

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📌 2. INDICATIONS — Kab Amputation Karte Hain?

A. Oncological (Cancer)

• Osteosarcoma (ہڈی کا کینسر — سب سے عام وجہ dogs میں) — forelimb mein zyada hota hai distal radius par
• Chondrosarcoma (cartilage cancer)
• Fibrosarcoma, Synovial cell sarcoma
• Soft tissue sarcomas jab limb-sparing possible na ho
• Cats mein: injection-site sarcomas

B. Trauma (چوٹ)

• Degloving injuries (جلد اور نرم بافت کا اُتر جانا) — road traffic accidents (RTA)
• Severe open/comminuted fractures (ٹکڑے ٹکڑے ہڈیاں) jab repair possible na ho
• Vascular injury (خون کی نالی کٹ جانا) with limb ischemia (خون نہ پہنچنا)
• Electrical burns, severe thermal injuries
• High-velocity gunshot wounds

C. Infection / Sepsis (انفیکشن)

• Osteomyelitis (ہڈی کی انفیکشن) — chronic, refractory (علاج نہ ہونے والی)
• Necrotizing fasciitis (گوشت کھانے والا بیکٹیریا)
• Gas gangrene (گینگرین)
• Severe septic arthritis unresponsive to treatment

D. Vascular / Neurological

• Aortic thromboembolism (ATE) in cats — acute hindlimb paralysis
• Brachial plexus avulsion (اگلی ٹانگ کی اعصابی جڑ ٹوٹنا) — forelimb pain + paralysis
• Lumbosacral nerve damage unresponsive

E. Congenital / Developmental

• Severe angular limb deformities — unrepairable
• Ischemic necrosis in neonates (پیدائشی خرابیاں)

F. Economic/Humane Reasons

• Jab limb salvage (ٹانگ بچانے کی کوشش) financially not feasible
• Non-functional, chronically painful limb ("dead weight" limb)

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📌 3. CONTRAINDICATIONS — Kab Nahi Karte?

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📌 4. ANATOMY — Amputation Levels

🐾 FORELIMB (اگلی ٹانگ) Anatomy

Scapula (کندھے کی ہڈی)
    ↓
Humerus (اوپری بازو)
    ↓
Radius + Ulna (کہنی سے نیچے)
    ↓
Carpus (کلائی — 7 bones)
    ↓
Metacarpals (1-5)
    ↓
Phalanges (پنجے کی ہڈیاں)

🐾 HINDLIMB (پچھلی ٹانگ) Anatomy

Pelvis / Acetabulum (کولہے کی ہڈی)
    ↓
Femur (ران کی ہڈی)
    ↓
Tibia + Fibula
    ↓
Tarsus/Hock (7 bones: calcaneus, talus etc.)
    ↓
Metatarsals (1-5)
    ↓
Phalanges

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📌 5. AMPUTATION TYPES (Level of Amputation)

🔴 FORELIMB — Types

Most common forelimb amputation in dogs = Forequarter (scapulothoracic) amputation — cosmetically best, eliminates "stump" (ٹھوٹھ) that can be painful

🔵 HINDLIMB — Types

Mid-femoral amputation is most commonly performed for hindlimb — adequate stump remains for mobility

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📌 6. PRE-OPERATIVE ASSESSMENT (آپریشن سے پہلے کا جائزہ)

A. Patient History & Signalment

• Age, breed, weight
• Duration of problem
• Previous treatments
• Concurrent diseases

B. Physical Examination

• Contralateral limb assessment (دوسری ٹانگ کی جانچ) — critical!
• Body weight/body condition score (BCS)
• Cardiovascular, respiratory exam
• Neurological exam — peripheral nerve function

C. Diagnostic Workup

Minimum Database:

• CBC (Complete Blood Count — خون کی مکمل گنتی): anemia, infection check
• Serum biochemistry (liver, kidney function)
• Coagulation panel — PT, aPTT (خون جمنے کے ٹیسٹ)
• Urinalysis

Imaging:

• Radiographs (X-rays):
  • Affected limb — 2 views minimum
  • Thoracic radiographs — 3 views (RIGHT lateral, LEFT lateral, VD) — lung metastasis check (پھیپھڑوں میں کینسر پھیلنے کی جانچ) — MANDATORY in tumor cases
  • Contralateral limb if suspected
• CT Scan: Tumor extent, vascular involvement, lymph node involvement — gold standard
• Bone scan (scintigraphy): Polyostotic lesions detect karna (کئی ہڈیوں میں بیماری)

Biopsy (ٹشو کا نمونہ):

• Incisional biopsy preferred for large tumors before amputation
• Tru-cut/core needle biopsy — less invasive
• Always send for histopathology

For Vascular Cases (Cats with ATE):

• Echocardiography (دل کا الٹراساؤنڈ) — hypertrophic cardiomyopathy rule out
• Coagulation studies
• Doppler ultrasound

D. Owner Counseling (مالک کو بتانا)

• Surgery ka purpose explain karo
• Prognosis — osteosarcoma mein amputation alone: median survival ~4-5 months; amputation + chemotherapy: ~12-16 months
• Post-op adaptation — 3-legged animals adapt very well (90%+ cases)
• Rehabilitation options
• Cost discussion
• Alternative options (limb-sparing — ٹانگ بچانا — discuss karo)

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📌 7. PRE-OPERATIVE PREPARATION (آپریشن کی تیاری)

A. Fasting (روزہ)

• Dogs: 8-12 hours NPO (nil per os — منہ سے کچھ نہیں) for food; water 2-4 hours before
• Cats: 6-8 hours food; 2-3 hours water

B. IV Access

• Large bore IV catheter — cephalic or saphenous vein
• IV fluids start: Lactated Ringer's Solution (LRS) or Normal Saline at maintenance rate

C. Pre-operative Medications

D. Regional Nerve Blocks (اعصابی بلاک)

• Forelimb: Brachial plexus block (axillary approach) — using lidocaine/bupivacaine
• Hindlimb: Lumbosacral epidural or femoral + sciatic nerve block
• Epidural: Morphine ± bupivacaine — excellent multimodal analgesia

E. Surgical Site Preparation

• Clip wide area — entire limb + beyond planned incision
• Sterile scrub: Chlorhexidine or Povidone-iodine — 3 alternating scrubs
• Patient positioning:
  • Forelimb: Lateral recumbency (جانب لیٹانا) affected side up, OR dorsal recumbency
  • Hindlimb: Lateral or dorsal recumbency

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📌 8. ANESTHESIA PROTOCOL (بے ہوشی کا طریقہ)

Induction (بے ہوش کرنا)

• Propofol 4-6 mg/kg IV (titrate to effect) — most common
• OR Alfaxalone 1-3 mg/kg IV

Maintenance (بے ہوشی قائم رکھنا)

• Isoflurane 1.5-2.5% in oxygen (سانس کی دوائی)
• OR Sevoflurane
• ETT (Endotracheal tube — سانس کی نلی) intubation mandatory

Monitoring (نگرانی)

• ECG — heart rhythm
• SpO2 (oxygen saturation — خون میں آکسیجن)
• ETCO2 (end-tidal CO2 — سانس میں CO2)
• Blood pressure — direct arterial (invasive) or indirect (Doppler/oscillometric)
• Temperature — hypothermia (جسم ٹھنڈا ہونا) common risk
• Urine output — urinary catheter recommended

Multimodal Analgesia (درد روکنے کا مکمل نظام)

1. Opioids (IV/IM)
2. Regional nerve blocks
3. NSAIDs (post-induction)
4. Ketamine CRI (Constant Rate Infusion) — 0.5 mg/kg loading → 10 mcg/kg/min
5. Lidocaine CRI (dog only) — 1-2 mg/kg bolus → 25-50 mcg/kg/min

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📌 9. SURGICAL PROCEDURE (آپریشن کا طریقہ)

🔴 FORELIMB AMPUTATION

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A. FOREQUARTER AMPUTATION (Scapulothoracic) — Most Common

• Elliptical (انڈاکار) incision: starts cranially over spine of scapula → arcs ventrally over the point of shoulder → continues down medial side of brachium (اوپری بازو)
• Caudal arm continues caudal to scapula

1. Incise skin and subcutaneous tissue over spine of scapula and down to axilla (بغل)
2. Divide omotransversarius muscle (scapula ko neck se جوڑنے والا)
3. Divide trapezius muscle (cranial and caudal parts) — along scapular spine
4. Reflect (ہٹانا) scapula ventrally — expose brachial plexus and axillary vessels
5. Identify and ligate (باندھنا) axillary artery and vein:
   • Double ligate (2 ligatures) proximal to amputation site
   • Use 2-0 or 0 absorbable suture (Vicryl/PDS) for vessels
   • Axillary artery must be ligated before vein (prevents engorgement)
6. Identify and transect brachial plexus nerves:
   • Individually identify: musculocutaneous, axillary, radial, median, ulnar nerves
   • Apply gentle traction, cut as proximally as possible (nerve retraction reduces neuroma — اعصابی گانٹھ)
   • Do NOT cauterize nerves — use sharp transection
7. Divide remaining muscles: Serratus ventralis, subscapularis, pectoral muscles
8. Remove limb — scapula included
9. Dead space closure (خالی جگہ بند کرنا):
   • Approximate muscle edges with absorbable suture (2-0 PDS/Vicryl)
   • Consider placing closed suction drain (Penrose or Jackson-Pratt) if large dead space
10. Subcutaneous layer closure: 2-0 or 3-0 absorbable interrupted sutures
11. Skin closure:
    • 3-0 nylon/polypropylene simple interrupted OR
    • Ford interlocking pattern
    • Or staples

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B. MID-HUMERAL AMPUTATION

• Less preferred — leaves painful stump
• Incise skin circumferentially, identify radial/ulnar/median nerves and vessels
• Ligate brachial artery and vein
• Transect humerus with bone saw (Gigli wire saw or oscillating saw)
• Smooth bone edges with rasp/rongeur (ہڈی کو چکنا کرنا)
• Myoplasty (عضلات کا ڈھکنا): oppose muscle groups over bone stump
• Close in layers

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🔵 HINDLIMB AMPUTATION

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A. MID-FEMORAL AMPUTATION — Most Common Hindlimb

• Circumferential skin incision at mid-femur level (approximately distal 1/3 of femur)
• Plan for generous skin flaps (جلد کی فلیپ) — enough to close without tension (کھنچاؤ کے بغیر)
• Mark skin 2-3 cm DISTAL to planned bone cut

1. Incise skin and subcutaneous tissue circumferentially
2. Reflect skin flaps proximally
3. Identify and ligate femoral artery and vein:
   • Femoral artery is in femoral triangle (ران کی ہڈی کے اندرونی حصے میں)
   • Double ligate with 2-0 absorbable suture — PROXIMAL ligation first
4. Identify and transect sciatic nerve:
   • Apply gentle traction on nerve
   • Cut as proximal as possible to minimize phantom pain/neuroma
   • Sharp transection — no electrocautery on nerve
5. Transect quadriceps (cranial) and hamstring group (caudal): biceps femoris, semimembranosus, semitendinosus
6. Expose femur at amputation level
7. Bone cut with oscillating saw or Gigli wire saw:
   • Make cut perpendicular (90°) to femoral shaft
   • Smooth sharp edges with bone rasp (فائل)
   • Flush with sterile saline
8. Myoplasty: Suture quadriceps to hamstrings over femur stump — covers bone end and provides cushioning (2-0 PDS)
9. Dead space management: Closed suction drain if needed
10. Subcutaneous closure: 2-0 absorbable interrupted
11. Skin closure: 3-0 monofilament simple interrupted or Ford interlocking

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B. COXOFEMORAL DISARTICULATION (Hip Joint Disarticulation)

1. Skin incision — cranial and caudal flaps over greater trochanter area
2. Divide iliotibial band, tensor fasciae latae
3. Identify femoral artery in femoral triangle — ligate and divide
4. Divide sciatic nerve — proximal, sharp cut
5. Incise joint capsule around femoral head
6. Transect round ligament (ligamentum teres) — releases femoral head from acetabulum (کولہے کا سوکٹ)
7. Divide remaining muscles (external rotators, gluteals)
8. Remove limb
9. Acetabulum: fill dead space with preserved muscles (reflected)
10. Close fascia, subcutaneous, skin in layers

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📌 10. INTRA-OPERATIVE CONSIDERATIONS (آپریشن کے دوران)

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📌 11. POST-OPERATIVE CARE (آپریشن کے بعد دیکھ بھال)

A. Immediate Recovery (فوری صحت یابی — پہلے 24 گھنٹے)

• Warm, padded recovery area — prevent hypothermia
• Oxygen supplementation — until fully awake
• IV fluids continue — reassess every 4-6 hours
• Pain monitoring:
  • Glasgow Composite Pain Scale
  • Colorado State Pain Scale
  • Signs: vocalization (آواز نکالنا), restlessness, tachycardia, hypertension, guarding

B. Analgesia (درد کم کرنا) Post-op

C. Wound Care (زخم کی دیکھ بھال)

• Elizabethan collar (E-collar — پلاسٹک کالر) — prevent self-trauma/licking
• Check incision daily:
  • Redness, swelling, discharge (لالی، سوجن، رطوبت)
  • Suture integrity
• Keep dry for 10-14 days
• Wound dehiscence risk (زخم کا کھل جانا) — watch for
• If drain present: empty BID, remove at 3-5 days when drainage <2 mL/day

D. Medications Post-op

E. Nutrition (غذائیت)

• Offer food within 6-8 hours of recovery
• Small meals initially
• Maintain ideal body weight — critical for remaining 3 limbs
• Weight management program if obese

F. Mobility & Exercise Restriction

• Week 1-2: Strict rest — sling support for hindlimb amputees
• Week 2-4: Short leash walks only, no stairs initially
• Week 4-8: Gradual return to activity
• By 6-8 weeks: Most patients ambulatory and adapted

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📌 12. COMPLICATIONS (پیچیدگیاں)

Early Complications (پہلے چند دن)

Late Complications (بعد میں)

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📌 13. SUTURE SELECTION (ٹانکوں کا انتخاب)

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📌 14. INSTRUMENTS REQUIRED (آلات)

• Scalpel (#10, #15 blade)
• Metzenbaum scissors (باریک قینچی)
• Mayo scissors
• Tissue forceps (thumb forceps, rat-tooth)
• Hemostatic forceps (Halsted mosquito, Kelly, Crile — خون روکنے کے clamps)
• Retractors: Gelpi, Weitlaner, Handheld (Army-Navy)
• Bone saw: Gigli wire saw OR oscillating/reciprocating bone saw
• Bone rongeur (ہڈی کاٹنا)
• Bone rasp/file (ہڈی چکنی کرنا)
• Periosteal elevator
• Suction apparatus
• Electrocautery (خون روکنے کے لیے)
• Sterile drapes and gowns

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📌 15. FORELIMB vs HINDLIMB — Key Differences

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📌 16. PROGNOSIS & OUTCOME (نتیجہ)

General:

• 90-95% of dogs and cats adapt excellently to 3-legged life ("Tripawd")
• Most are ambulatory within 2-4 weeks
• Quality of life studies show no significant difference from 4-legged dogs

Disease-Specific:

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📌 17. SPECIAL CONSIDERATIONS

Cats vs Dogs:

• Cats are generally lighter — adapt faster
• Cats may be more psychologically sensitive — quiet recovery environment
• Cats have more flexible spine — balance better
• NSAIDs — cats very sensitive (hepatotoxicity risk) — Meloxicam at much lower doses, short term only

Large Breed Dogs:

• Forequarter amputation preferred (no stump)
• Weight management critical
• Consider joint supplementation (glucosamine, omega-3) for remaining limbs

Pediatric/Young Animals:

• Excellent adaptation
• Bone grows rapidly — concern about remaining limb overload less

Geriatric Animals:

• Higher anesthesia risk
• Pre-op cardiac/renal workup more important
• May take longer to adapt

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📌 18. REHABILITATION (بحالی)

• Physiotherapy starts Day 2-3 post-op: passive range of motion (پاسیف حرکت)
• Hydrotherapy (پانی میں ورزش) — underwater treadmill — Week 3-4
• Massage of remaining limbs
• Balance exercises — Wobble boards
• Core strengthening
• Prosthetics/orthotic devices — available but less commonly used in animals

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📌 19. OWNER EDUCATION (مالک کو ہدایات)

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📌 SUMMARY TABLE — Quick Reference

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• Fossum TW — Small Animal Surgery, 4th & 5th Edition (Elsevier)
• Slatter DH — Textbook of Small Animal Surgery, 3rd Edition
• Tobias KM & Johnston SA — Veterinary Surgery: Small Animal, 2nd Edition
• Piermattei DL, Flo GL, DeCamp CE — Handbook of Small Animal Orthopedics and Fracture Repair, 4th Edition
• Veterinary Society of Surgical Oncology (VSSO) Guidelines

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LIMB AMPUTATION IN DOGS & CATS

A Comprehensive Veterinary Surgery Reference for Vet Students

Based on: Fossum's Small Animal Surgery | Slatter's Textbook of Small Animal Surgery | Tobias & Johnston's Veterinary Surgery | Rockwood & Green's Fractures (surgical principles)

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SECTION 1 — FUNDAMENTALS

1.1 Definition

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1.2 Goals of Amputation Surgery

1. Remove the diseased or non-functional limb completely
2. Provide a pain-free patient post-operatively
3. Create a well-healed, comfortable residual stump (when applicable)
4. Minimize dead space to reduce seroma and infection risk
5. Preserve maximum limb length compatible with disease-free margins
6. Enable rapid patient rehabilitation and return to ambulatory function

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SECTION 2 — INDICATIONS (When to Amputate)

2.1 Oncological Indications (Most Common in Dogs)

• Tumor involves >50% of the bone circumference
• Tumor extends to the joint
• Pathologic fracture is present
• Neurovascular bundle is involved
• Owner cannot afford limb-sparing surgery

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2.2 Traumatic Indications

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2.3 Infectious Indications

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2.4 Neurological Indications

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2.5 Vascular Indications

• Feline aortic thromboembolism (FATE/ATE): Cardiomyopathy → thrombus occludes aortic trifurcation → acute hindlimb ischemia. Amputation if limb non-viable after 24–48 hours.
• Arteriovenous fistula (abnormal artery-vein connection) — uncontrollable
• Ischemic necrosis — neonatal strangulation injuries

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2.6 Miscellaneous / Economic Indications

• Severe angular limb deformity — unrepairable; non-ambulatory
• Chronic non-healing wound overlying infected bone
• Humane reasons: When the cost of reconstruction is prohibitive and the limb remains non-functional and painful
• Owner preference after thorough counseling of all options

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SECTION 3 — CONTRAINDICATIONS

3.1 Absolute Contraindications

3.2 Relative Contraindications (Must Be Individually Evaluated)

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SECTION 4 — PATIENT EVALUATION & DIAGNOSTIC WORKUP

4.1 Signalment and History

• Species, Breed, Age, Sex, Weight — critical for dosing and prognosis
• Duration and progression of the problem
• Previous treatments (surgeries, medications, chemotherapy)
• Concurrent diseases (cardiac, renal, hepatic)
• Vaccination and parasite status
• Owner's financial and lifestyle expectations

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4.2 Physical Examination

General Assessment:

• Body condition score (BCS 1–9)
• Hydration status
• Cardiovascular: heart rate, rhythm, murmur
• Respiratory: rate, effort, auscultation
• Abdominal palpation
• Lymph node palpation (especially regional nodes — inguinal, axillary, popliteal)

Orthopedic/Neurological Exam of Affected Limb:

• Pain assessment: pain on palpation, manipulation
• Swelling, firmness, heat — bone vs. soft tissue
• Range of motion of adjacent joints
• Deep pain perception (DPP): toe pinch reflex — critical in trauma/neurological cases
• Proprioception (position-sensing ability)
• Muscle atrophy (wasting)

Contralateral Limb Assessment — CRITICAL:

• Full orthopedic exam of the limb that will carry extra weight post-operatively
• Any pre-existing osteoarthritis, fracture, or neurological deficit must be documented
• If contralateral limb is also severely compromised → reconsider amputation

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4.3 Minimum Database (Pre-anesthetic Bloodwork)

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4.4 Imaging

Radiography:

• Affected limb — minimum 2 orthogonal views:
  • Assess tumor extent, bone destruction, pathologic fracture
  • Determine amputation level
• Thoracic radiographs — 3 views (Right lateral, Left lateral, VD):
  • MANDATORY in all tumor cases
  • Detect pulmonary metastases (lung spread)

  • 3 pulmonary nodules → guarded to poor prognosis even with amputation

• Contralateral limb: If clinical suspicion of disease
• Spine: If neurological deficits present

Advanced Imaging:

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4.5 Biopsy (Tissue Sampling)

• Always biopsy before amputation if cancer suspected — confirm diagnosis
• Core needle (Tru-cut) biopsy: Minimally invasive; ultrasound-guided preferred
• Incisional biopsy: Small wedge of tumor removed; more tissue, higher accuracy
• Excisional biopsy: Removing the whole tumor — only if tumor is small and removable
• Submit all specimens for histopathology
• Place biopsy tract in line with planned amputation incision — so the tract is removed with the limb

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4.6 Owner Communication (Informed Consent)

1. Diagnosis and why amputation is recommended
2. Alternative options (limb-sparing, radiation, palliative care) and why each may or may not be appropriate
3. Surgical risks: hemorrhage, anesthesia complications, wound breakdown, infection
4. Post-operative prognosis:
   • Osteosarcoma (amputation alone): median survival 4–5 months
   • Osteosarcoma (amputation + adjuvant chemotherapy with carboplatin/cisplatin): 10–16 months
   • Trauma / benign disease: Excellent — near-normal lifespan
5. Adaptation: 90%+ of dogs and cats become fully functional on 3 limbs within 2–8 weeks
6. Post-op care requirements and costs
7. Quality of life studies — tripod animals show no significant reduction in QoL scores

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SECTION 5 — SURGICAL ANATOMY

5.1 Forelimb Anatomy

Skeletal Structure:

Scapula (shoulder blade)
     ↓ — Glenohumeral (shoulder) joint
  Humerus
     ↓ — Elbow joint (humeroulnar + humeroradial)
  Radius + Ulna (antebrachium)
     ↓ — Carpal joint (carpus = 7 bones: radial, ulnar, accessory, 1st–4th carpal)
  Metacarpals (I–V)
     ↓
  Proximal phalanx → Middle phalanx → Distal phalanx (claw)

Vascular Supply:

• Axillary artery (in axilla/armpit) → Brachial artery (medial humerus) → branches into Radial artery + Median artery + Ulnar artery
• The axillary vein runs alongside — both must be ligated in forequarter amputation
• Cephalic vein: runs on lateral antebrachium — commonly used for IV catheter

Nerve Supply (Brachial Plexus — C6 to T2):

Key Muscles (Forequarter):

• Superficial: Trapezius (cervical + thoracic parts), omotransversarius, brachiocephalicus
• Deep/Intrinsic: Supraspinatus, infraspinatus, subscapularis, serratus ventralis
• Arm muscles: Triceps brachii (3 heads), biceps brachii, brachialis

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5.2 Hindlimb Anatomy

Skeletal Structure:

Pelvis → Acetabulum (hip socket)
     ↓ — Coxofemoral (hip) joint
  Femur
     ↓ — Stifle (knee) joint: femur + tibia + patella
  Tibia + Fibula (crus)
     ↓ — Tarsal (hock) joint: calcaneus, talus, central, 1st–4th tarsal
  Metatarsals (I–V)
     ↓
  Phalanges (3 per digit)

Vascular Supply:

• External iliac artery → Femoral artery (femoral triangle, medial thigh) → Popliteal artery → Cranial tibial + Caudal tibial arteries
• Femoral vein runs medial to femoral artery
• The femoral artery and vein are the key vessels ligated in mid-femoral amputation

Nerve Supply:

Key Muscles (Hindlimb):

• Caudal (ham) group: Biceps femoris, semimembranosus, semitendinosus — hip extension + stifle flexion
• Cranial group: Quadriceps femoris (rectus femoris + vastus lateralis/medialis/intermedius) — stifle extension
• Hip extensors: Gluteus medius, gluteus superficialis, piriformis
• Hip adductors: Gracilis, adductor magnus, pectineus

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SECTION 6 — AMPUTATION LEVELS

6.1 Forelimb Amputation Levels

Preferred in clinical practice: Forequarter amputation — no stump = no pressure sores, better cosmetic result, and eliminates all tumor tissue even with proximal extension.

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6.2 Hindlimb Amputation Levels

Preferred in clinical practice: Mid-femoral amputation — ideal stump length for mobility, adequate muscle coverage of bone end.

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SECTION 7 — PRE-OPERATIVE PREPARATION

7.1 Patient Stabilization

• Correct anemia: packed red blood cells (pRBC) transfusion if PCV <20% (dogs) / <15% (cats)
• Correct dehydration: IV crystalloid fluids (Lactated Ringer's Solution or Plasma-Lyte)
• Correct coagulopathy: fresh frozen plasma (FFP) if PT/aPTT prolonged >1.5× normal
• Pain management prior to surgery: pre-emptive analgesia reduces wind-up (sensitization of pain pathways)

7.2 Fasting Protocol (NPO — Nothing Per Os)

• Dogs: Food withheld 8–12 hours; water withheld 2–4 hours before induction
• Cats: Food withheld 6–8 hours; water withheld 2–3 hours
• Pediatric patients (<8 weeks) or hypoglycemia-prone: shorten fast and monitor blood glucose

7.3 Intravenous Access

• Place large-bore IV catheter (20–22G cat; 18–20G dog)
• Site: cephalic vein (antebrachium) or saphenous vein
• Avoid the limb being amputated — it will be prepped into the surgical field
• Begin IV crystalloid fluids at 5–10 mL/kg/hr

7.4 Pre-operative Antibiotic Prophylaxis

• Cefazolin (first-generation cephalosporin): 22 mg/kg IV — administered 30 minutes before skin incision
• Re-dose every 90 minutes if surgery exceeds that time
• Contaminated/infected wounds: broader spectrum (e.g., enrofloxacin + metronidazole)

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SECTION 8 — ANESTHESIA PROTOCOL

8.1 Pre-medication (Pre-med)

Note: Acepromazine is avoided in patients with hypotension, arrhythmia, or severe cardiac disease. Dexmedetomidine is avoided in cats with hypertrophic cardiomyopathy.

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8.2 Induction (Making the Patient Unconscious)

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8.3 Maintenance (Keeping the Patient Anesthetized)

• Isoflurane 1.5–2.5% in 100% oxygen — most commonly used inhalant anesthetic
• Sevoflurane 2.5–3.5% — faster recovery; better in cats
• Deliver via rebreathing circuit (>7 kg) or non-rebreathing circuit (<7 kg, cats)
• Oxygen flow rate: 30–50 mL/kg/min (non-rebreathing); 20–30 mL/kg/min (rebreathing)

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8.4 Intra-operative Analgesia (Pain Management During Surgery)

Multimodal Balanced Anesthesia:

Regional Nerve Blocks (Locoregional Anesthesia):

• Axillary approach: needle inserted cranial to the first rib, medial to the shoulder
• Drug: Bupivacaine 0.25–0.5% — 0.1 mL/kg per nerve root (total volume not to exceed 1–2 mg/kg bupivacaine total)
• Duration: 4–8 hours of analgesia
• Alternatively: ultrasound-guided brachial plexus block — more accurate

• Femoral nerve block: Inguinal approach; block before femoral triangle
• Sciatic nerve block: Lateral approach at mid-femur
• Drug: Bupivacaine 0.25% ± morphine or buprenorphine as adjuvant
• Duration: 6–12 hours

• Most reliable hindlimb regional block
• Site: L7–S1 junction (lumbosacral space)
• Drug combinations:
  • Morphine 0.1 mg/kg alone (up to 24 hours analgesia) OR
  • Bupivacaine 0.5% (1 mg/kg) + Morphine 0.1 mg/kg (4–8 hours)
• Contraindicated if: coagulopathy, infection at site, spinal pathology

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8.5 Intra-operative Monitoring

Fluid Therapy During Surgery:

• LRS (Lactated Ringer's Solution): 5–10 mL/kg/hr maintenance
• Blood loss replacement: 3 mL crystalloid : 1 mL blood lost
• If significant hemorrhage: colloids (hydroxyethyl starch 5 mL/kg bolus) OR pRBC transfusion
• Warm IV fluids to prevent hypothermia (use fluid warmer)

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SECTION 9 — SURGICAL TECHNIQUE

9.1 General Principles (Applicable to All Amputations)

1. Skin flaps must be generous — plan more skin than you think you need; closure under tension leads to dehiscence
2. Double ligate all vessels — suture ligatures (transfixion) for large vessels; clips for small
3. Nerve transection: Apply gentle traction → cut sharply and as proximally as possible → allow nerve to retract under tension; this minimizes neuroma formation
4. Bone cut: Irrigate continuously with sterile saline while sawing to prevent thermal bone necrosis
5. Smooth bone edges with bone rasp after cutting — eliminates sharp points that erode through skin
6. Myoplasty: Suture opposing muscle groups over the bone end — provides padding, obliterates dead space, and improves residual limb shape
7. Hemostasis before closure — release tourniquet, identify bleeders, achieve complete hemostasis

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9.2 FOREQUARTER AMPUTATION (Forelimb)

(Scapulothoracic Amputation — Entire Forelimb + Scapula Removed)

• Lateral recumbency — affected side uppermost
• Entire limb, shoulder, and lateral thorax clipped and surgically prepped
• Limb draped free (mobile limb in the sterile field)

• Cranial arm: begins at the spine of the scapula → curves cranially over the acromion process → continues down the craniomedial aspect of the brachium (upper arm)
• Caudal arm: continues caudal to the scapula → joins the cranial arm in the axillary region
• The two incisions form an ellipse around the shoulder/axilla
• The skin over the scapular spine is included in the incision (not undermined)

• Incise through skin and subcutaneous tissue
• Divide brachiocephalicus muscle cranially (along its cranial border)
• Divide omotransversarius muscle at its insertion on the spine of the scapula
• Divide trapezius muscle (both cervical and thoracic portions) along the scapular spine

• Retract (pull back) the scapula ventrally and laterally
• This exposes the deep structures: axillary vessels and brachial plexus

• Identify the axillary artery and axillary vein in the axillary space
• Ligate the axillary artery first (before vein) — prevents engorgement
• Apply double transfixion suture ligatures using 2-0 PDS or Vicryl
• Transect between ligatures
• Ligate and transect axillary vein similarly

• Individually identify each nerve root: musculocutaneous, axillary, radial, median, ulnar, thoracodorsal
• Apply gentle distal traction on each nerve
• Using sharp scissors or a #15 blade, cut each nerve as proximally as possible — allowing it to retract
• Do NOT use electrocautery on nerves — causes neuroma and phantom pain

• Divide serratus ventralis (thoracis portion) from its costal attachments — this is the final attachment holding the scapula to the thorax
• Divide subscapularis at its insertion on the lesser tubercle of the humerus
• Divide pectoral muscles (superficial and deep) medially

• With all vascular, neural, and muscular attachments divided, the entire forelimb and scapula are removed as a single unit

• Release tourniquet if used
• Inspect the entire wound for bleeding
• Electrocautery for small bleeders; additional ligatures for larger vessels

• If significant dead space remains: place a closed active drain (Jackson-Pratt or Blake drain)
• Exit drain through a separate stab incision caudal to the main incision
• Secure with a finger-trap suture

• Deep muscle layer: Approximate serratus ventralis to pectoral muscles with 2-0 PDS interrupted sutures — eliminates dead space
• Subcutaneous layer: 2-0 or 3-0 Vicryl/Monocryl simple interrupted
• Skin: 3-0 nylon (Ethilon) simple interrupted or Ford interlocking (everting) pattern

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9.3 MID-HUMERAL AMPUTATION

1. Mark circumferential skin incision 2–3 cm distal to planned bone cut — allows skin flap for tension-free closure
2. Incise skin and subcutaneous tissue circumferentially
3. Reflect skin flaps proximally
4. Identify brachial artery and vein on the medial surface of the humerus — double ligate
5. Identify and transect radial, median, and ulnar nerves — proximally, under traction
6. Divide triceps brachii (caudal) and biceps + brachialis (cranial) at the planned transection level
7. Periosteal elevation at bone cut site — protect soft tissues
8. Bone cut with oscillating saw — perpendicular to long axis; continuous saline irrigation
9. Rasp all bone edges smooth
10. Myoplasty: Suture cranial and caudal muscle groups over the bone stump
11. Drain placement if needed
12. Close subcutaneous + skin in layers

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9.4 MID-FEMORAL AMPUTATION (Hindlimb)

(Most Common Hindlimb Procedure)

• Lateral recumbency — affected side uppermost
• Clip from dorsal midline to ventral midline; include entire hindlimb
• Entire limb draped free

• Circumferential incision at mid-femur level (approximately 50–60% of femoral length from greater trochanter)
• Plan skin flaps 2–3 cm distal to the planned bone cut
• Mark both cranial and caudal flaps — caudal flap often made slightly longer for easier closure

• Incise skin and subcutaneous tissue circumferentially at the marked level
• Reflect skin flaps proximally to expose the femoral musculature

• The femoral artery and vein are located in the femoral triangle on the medial surface of the thigh
• Gently dissect the femoral artery from the femoral vein with right-angle forceps
• Ligate femoral artery first (double transfixion suture — 2-0 PDS); then femoral vein
• Transect between ligatures

• The sciatic nerve runs in the caudal compartment of the thigh, dorsal to the biceps femoris
• Apply gentle distal traction on the nerve
• Transect sharply as proximal as possible — allowing it to retract
• This is the single most important step for preventing post-operative neuropathic pain

• Cranial group: Divide quadriceps femoris (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius) at the amputation level
• Caudal group: Divide biceps femoris, semimembranosus, semitendinosus at the same level
• Medial: Divide gracilis and adductor muscles
• Lateral: Divide tensor fasciae latae

• Elevate the periosteum (bone covering) with a periosteal elevator at the planned cut site
• Using an oscillating bone saw or Gigli wire saw:
  • Cut perpendicular (90°) to the long axis of the femur
  • Continuous sterile saline irrigation to prevent thermal necrosis
• Remove the distal limb

• Use a bone rasp (file) to eliminate all sharp bony prominences
• Flush wound with copious sterile saline (500–1000 mL)

• Suture quadriceps (cranial) to hamstrings (caudal) over the distal femoral stump
• Use 2-0 PDS interrupted sutures
• This: (a) covers the bone end, (b) prevents bone prominences, (c) obliterates dead space, (d) improves stump shape and function

• Place closed active drain (Jackson-Pratt) if large dead space; exit through separate stab incision

• Fascial layer: 2-0 PDS simple interrupted
• Subcutaneous layer: 3-0 Vicryl/Monocryl simple interrupted
• Skin: 3-0 nylon simple interrupted or Ford interlocking

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9.5 COXOFEMORAL DISARTICULATION (Hip Disarticulation)

• Cranial and caudal skin flaps ("fishmouth" shape) centered over the greater trochanter
• Incision extended to allow generous flap coverage

1. Divide tensor fasciae latae and gluteal muscles (gluteus superficialis, medius, profundus)
2. Identify and ligate femoral artery in the femoral triangle (inguinal region) — before entering deep dissection
3. Divide quadriceps insertion on the femur proximally
4. Identify and transect sciatic nerve — proximal, under traction, sharp cut
5. Transect biceps femoris, semimembranosus, semitendinosus at their origin
6. Incise the coxofemoral joint capsule circumferentially
7. Transect the round ligament (ligamentum teres) — releases the femoral head from the acetabulum
8. Divide remaining muscles (obturators, gemelli, quadratus femoris)
9. Remove the limb
10. Redirect and interdigitate remaining muscles over the empty acetabulum — fill dead space
11. Drain placement
12. Close fascia → subcutaneous → skin

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9.6 INSTRUMENT REQUIREMENTS

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SECTION 10 — SUTURE SELECTION

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SECTION 11 — POST-OPERATIVE MANAGEMENT

11.1 Immediate Recovery Phase (0–24 Hours)

• Recovery in a warm, quiet, padded area — prevent hypothermia (use forced-air warmer, warm blankets, warm IV fluids)
• Supplemental oxygen via flow-by or mask until fully sternal
• Monitor SpO2, heart rate, respiratory rate, temperature, blood pressure continuously in the first 2–4 hours
• IV fluid therapy continues post-op; reassess hydration and urine output every 4–6 hours
• Monitor surgical site: hemorrhage, swelling, seroma formation

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11.2 Post-operative Pain Management

Multi-modal Analgesia Protocol:

Important: Cats are extremely sensitive to NSAIDs — use lowest effective dose for shortest necessary duration. Never use acetaminophen (paracetamol) in cats — it is FATAL.

Pain Scoring (use standardized scales):

• Glasgow Composite Pain Scale (GCPS) — validated in dogs
• Colorado State University Pain Scale — cats and dogs
• Signs of pain: vocalization, restlessness, tachycardia, hypertension, guarding/posturing, aggression, reluctance to move

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11.3 Wound Management

• Elizabethan collar (E-collar) must be worn at all times — prevent self-trauma to incision
• Keep wound dry for 10–14 days — no bathing
• Watch for: dehiscence (suture line opening), seroma (fluid pocket), hematoma, infection (redness, heat, purulent discharge, fever)

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11.4 Post-operative Medications Summary

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11.5 Nutritional Management

• Offer small, bland meals 6–8 hours after full recovery from anesthesia
• Normal diet resumed gradually over 2–3 days
• Maintain ideal body weight (BCS 4–5/9) — this is critical
• Obese patients placed on weight management diet
• Joint supplements: omega-3 fatty acids (EPA/DHA), glucosamine + chondroitin — for the remaining limbs' joints

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11.6 Exercise and Mobility Progression

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11.7 Rehabilitation Therapy

• Physical therapy begins Day 2–3 post-op:
  • Passive range-of-motion (PROM) exercises for remaining limb joints
  • Gentle massage of stump and remaining limbs
• Week 3–4: Hydrotherapy — underwater treadmill — reduces weight bearing on joints while building muscle
• Core strengthening exercises — critical for long-term spinal health (especially important in hindlimb amputees)
• Balance/proprioception training: Cavaletti poles, balance discs, wobble boards
• Prosthetics: Available but infrequently used in veterinary patients; most animals function well without them

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SECTION 12 — COMPLICATIONS

12.1 Early Complications (Within First 7 Days)

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12.2 Late Complications (After 2 Weeks)

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SECTION 13 — SPECIAL CONSIDERATIONS

13.1 Cats vs. Dogs — Key Differences

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13.2 Brachial Plexus Avulsion — Special Case

• Mechanism: Usually road traffic accident; traction injury to the forelimb while the body moves in opposite direction
• Presentation: Forelimb paralysis; knuckling; muscle atrophy; loss of deep pain perception; self-mutilation of desensitized limb
• Diagnostic confirmation: EMG (electromyography), myelography, or CT myelography
• Treatment: If DPP absent for >4–6 weeks → forequarter amputation indicated
• Post-op prognosis: Excellent for quality of life once paralyzed, painful limb is removed

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13.3 Aortic Thromboembolism (ATE) in Cats — Special Case

• Pathophysiology: Hypertrophic cardiomyopathy → left atrial enlargement → thrombus formation → embolism lodges at aortic trifurcation (saddle thrombus)
• Clinical signs: Acute onset hindlimb paralysis; cold limbs; absent femoral pulses; cyanotic (blue/grey) toe pads; extreme pain; vocalizing
• Emergency management:
  • Analgesia: buprenorphine OTM + gabapentin
  • Heparin anticoagulation
  • Echocardiography to assess cardiac function
  • Supportive care: warmth, fluids, anti-arrhythmics
• Amputation: Reserved for limbs that remain non-viable (cold, necrotic) after 24–48 hours of medical management; or when limb partially recovers but remains severely painful/non-functional
• Prognosis: Guarded — depends entirely on underlying cardiac disease; many cats have recurrence within 6 months

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13.4 Pediatric Patients (Puppies and Kittens)

• Adaptation is fastest in young animals — excellent prognosis
• Shorter fasting periods required — monitor blood glucose
• Smaller vessels — use fine sutures (3-0 or 4-0 for vascular ligation)
• Healing is faster
• Long-term concern: spinal and contralateral limb development

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13.5 Geriatric and High-Risk Patients

• Pre-operative workup must be thorough: cardiac, renal, hepatic function
• Reduced anesthetic drug doses; titrate to effect
• Hypothermia risk higher — aggressive warming
• Healing slower — leave sutures in for 14–21 days
• More frequent post-op monitoring
• Discuss realistic expectations with owner

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SECTION 14 — PROGNOSIS

14.1 Disease-Specific Prognosis

14.2 Functional Outcomes

• 90–95% of dogs and cats are fully ambulatory on 3 limbs within 4–8 weeks
• Multiple quality-of-life studies demonstrate no significant difference in QoL scores between tripod animals and intact animals
• Owners often report better QoL post-amputation vs. when animal was suffering from a painful limb
• Term "Tripawd" is widely used in the veterinary oncology community — an established, successful rehabilitation category

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SECTION 15 — OWNER DISCHARGE INSTRUCTIONS

• Fever (rectal temp >39.5°C)
• Rapid swelling at surgical site
• Wound opening or tissue visible
• Refusal to eat for >24 hours
• Severe uncontrollable pain

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QUICK REFERENCE SUMMARY TABLE

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• Fossum TW. Small Animal Surgery, 5th ed. Elsevier, 2019
• Slatter DH. Textbook of Small Animal Surgery, 3rd ed. Saunders, 2003
• Tobias KM, Johnston SA. Veterinary Surgery: Small Animal, 2nd ed. Elsevier, 2018
• Piermattei DL, Flo GL, DeCamp CE. Handbook of Small Animal Orthopedics and Fracture Repair, 4th ed.
• Rockwood & Green. Fractures in Adults, 10th ed. Wolters Kluwer, 2025 — (Amputation principles, transfemoral & transtibial technique, myoplasty, neurovascular transection)
• Dernell WS et al. Vail DM, Thamm DH, Liptak JM. Withrow & MacEwen's Small Animal Clinical Oncology, 6th ed.