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Soft Tissue

Soft Tissue surgery specialises in treating dogs and cats that require surgery to treat conditions that involve organs, the intestines, liver, kidneys, bladder, lungs, heart along with skin and muscle.

Our soft tissue team consists of Ben Mielke, Jane Ladlow and Michael Hamilton. We are supported by a team of anaesthetists, imagers and nurses to ensure the patient has a smooth journey through the treatment process. We can offer a comprehensive surgical referral service, including:

  • BOAS surgery
  • Abdominal Surgery
  • ENT Surgery
  • Foreign Bodies
  • Genitourinary Surgery
  • Oncological Surgery
  • Thoracic Surgery
  • Skin and reconstruction Surgery
  • Hernia Repair

We also have a brachycephalic clinic that provides a world leading specialist service for these breeds.

Routine appointments are available Monday to Friday. The team is happy to receive emergency case transfers and to receive clinical enquiries including review of imaging studies and wound photographs.

  • BOAS - Brachycephalic Obstructive Airway Syndrome
  • Perineal Hernia
  • Portosystemic Shunts (PSS)
  • Total Ear Canal Ablation (TECA) and Lateral Bulla Osteotomy (LBO)
  • Wound Management

BOAS - Brachycephalic Obstructive Airway Syndrome

Hamilton Specialist Referrals offers a specialist clinic for brachycephalic dog breeds, also known as short-muzzled or short-nosed dogs. Brachycephalic dogs can suffer from long-term health problems that affect their breathing, eyes, bones and gait, heart, skin and ears.

These dogs have compressed skulls that result in overcrowding of the soft tissue within the skull and are at risk of developing respiratory problems such as brachycephalic obstructive airway syndrome (BOAS). We see this condition more commonly in certain breeds, with Pugs, English Bulldogs and French Bulldog over-represented.

What are the signs of BOAS?

The most common clinical signs include:

  • breathing difficulties
  • noise whilst breathing
  • regurgitation
  • gagging
  • reduced exercise tolerance

Some of our patients will have periods of sleep apnoea and associated restlessness at night – owners may note their dog sleeping with a toy or object in their mouth

When to refer a case for BOAS assessment?

If you are concerned about a patient with the clinical signs above please contact us to arrange a referral. Research has shown that early intervention is likely to result in a better outcome for the patient.

Our approach:

We will perform an initial assessment of these patients which includes a full historical assessment, exercise tolerance test, airway assessment and diagnostic imaging.


Rhinoscopic view of the nasopharynx   


Alar fold (inner nostril)


Image of a Laryngeal collapse  


CT evaluation of the airway

We use this information to decide the best surgical and post-surgical management strategy. Typically, surgery will involve a palatoplasty (reducing the length and thickness of the soft palate), laryngeal sacculectomy and rhinoplasty (widening of the nostrils).


Modified folding flap. Palatoplasty end of surgery (soft palate resection)


Palate surgery healed, 6 weeks post op

In some cases we may need to perform more advanced surgery to open the airway within the nostrils. This procedure (turbinectomy) uses a laser to remove some of the tissue within the nasal passageway.

 Rhinoplasty (widening of the nostrils) to improve airflow


One of our patients wearing their protective eyewear essential for laser treatment.

What are the potential complications of Surgery?

Surgery is aimed to improve the flow of air through a restricted airway. Because of the nature of this condition it is not always possible to completely resolve the underlying airway compromise. For these patients a degree of airway compromise will remain despite appropriate surgery.

Patients with respiratory compromise do have an increased risk of anaesthetic complications – as such we work closely with our Anaesthesia specialists to make any intervention as safe as possible.

Perineal Hernia

Perineal Rupture or Perineal Hernia

A perineal hernia is a result of weakness or separation of the muscles of the pelvic diaphragm. These muscles are situated around the rectum, pelvis and the base of the tail. An abnormal hole in or between these muscle allows fat or sometimes abdominal organs to bulge into the perineal area.

This is a condition commonly seen in older, male, entire dogs but other animals may also be affected. In male dogs, male hormone levels can result in weakness in the muscle diaphragm. Couple with conditions that cause straining when toileting or conditions that increase the pressure in the abdomen and failure of the pelvic diaphragm muscles can occur.

Common risk factors for this condition include:

  • Entire (uncastrated) males
  • Disease of the reproductive system (eg. Tumour of the testes)
  • Enlargement of the prostate (benign enlargement, tumours, cystic swellings)
  • Straining due to colitis or pregnancy

Clinical signs of perineal hernia include:

  • Swelling of the perineum
  • Bruising of the perineum
  • Difficulty passing urine – cases that present unable to urinate may be considered a surgical emergency and will need urgent referral for stabilisation and surgery
  • Constipation, pain or straining to pass stool

What happens when a case is referred for treatment of a perineal hernia?

Because there are a range of reasons an animal may present with a perineal hernia we will aim to identify any underlying conditions. Common investigation for these patients includes:

  • Blood tests
  • Urinalysis
  • Abdominal imaging (ultrasound scan of the urogenital system, prostate, etc)
  • Rectal examination

How are perineal hernias treated?

Repair of a perineal hernia requires a surgery. This involves repair of the muscle of the diaphragm, in addition to moving some local muscles to stabilise the repair. In severe or recurrent hernias it may involve mobilisation of muscles from a hindleg or use of a synthetic mesh.

Further support for the repair can be given by fixing the bladder and colon (large intestine) into the abdomen but this is not necessary in all cases.

In male dogs we will typically recommend castration.

What can I expect following surgery?

Most cases will recover uneventfully after surgical treatment. Despite this, complications can occasionally occur. The common complications we see after perineal hernia surgery include:

  • Recurrence of the rupture; stool softeners may be advised long term to reduce the straining during defaecation and therefore protect the repair
  • Rupture of the other side
  • Infection: the surgical site is in the perineal region, near to the anus which is a source of bacteria
  • Faecal incontinence; uncommon and usually temporary

Portosystemic Shunts (PSS)

Portosystemic Shunts

A portosystemic shunt (PSS) is an abnormal connection between the portal vascular system and systemic circulation. Blood from the abdominal organs which should be drained by the portal vein into the liver is instead shunted to the systemic circulation by the PSS. This means that a portion of the toxins, proteins and nutrients absorbed by the intestines bypass the liver and are shunted directly into the systemic circulation.

There are two categories of congenital shunts, extrahepatic (outside the liver) and intrahepatic (inside the liver). While most portosystemic shunts are congenital (the dog or cat is born with the shunt), under certain circumstances portosystemic shunts may be acquired secondary to another problem with the liver (acquired shunts).

The genetic basis of PSS in dogs is unknown, but it is considered congenital and breeds affected include:

  • Miniature schnauzers
  • Yorkshire terriers
  • Irish wolfhounds
  • Cairn terriers
  • Maltese

Single extrahepatic shunts are typically congenital and affect small and toy breeds whereas single intrahepatic shunts affect large breeds. Cats nearly always have extrahepatic shunts.

Presenting Features:

Animals with congenital portosystemic shunts may present for:

  • anaesthetic intolerance - prolonged recovery following an anaesthetic event
  • small body stature
  • behavioural abnormalities

The signs are often episodic and may be more noticeable after eating. These neurological signs are due to the hepatic encephalopathy syndrome.

Signs of abnormal neurologic function include:

  • ataxia (swaying as if intoxicated)
  • seizures
  • blindness
  • head pressing

Other signs may include:

  • anorexia (loss of appetite)
  • vomiting
  • diarrhoea
  • constipation
  • ptyalism (hypersalivation) – most frequently seen in cats
  • polyuria/polydipsia (excessive urination/drinking)
  • stranguria (difficulty urinating)
  • haematuria (blood in the urine)

If your primary care veterinarian suspects that your pet has a portosystemic shunt, a full diagnostic work-up is advised. Some of these diagnostics may be completed by your primary care veterinarian, but you may also be referred to an ECVS board-certified veterinary surgeon or veterinary specialty center for additional diagnostics. A full work-up may include:

  • blood work
  • urinalysis
  • ultrasound
  • portography (an x-ray dye study that specifically highlights the portal system
  • liver function tests (bile acids and ammonia) Bile acids are measured after an overnight fast ("preprandial" or fasting) and then 2 hours after eating ("postprandial"). In dogs with PSS, one or both sets of bile acids are increased. Bile acids can increase with any liver disease, so high bile acids are not specific to congenital portosystemic shunts
  • CT scan with intravenous contrast

We recommend that any patient that is diagnosed with a portosystemic shunt is referred for a discussion on surgical management. Preoperatively we recommend that patients are treated with:

  • Lactulose
  • Purina HA Diet

At HSR surgery will depend on the exact nature of the shunt and the vascular development of the liver. We will typically encounter several common scenarios:

  • Partial attenuation – When you cannot completely ligate the shunting vessel we will typically perform a partial attenuation (narrowing of the shunt). Narrowing of the shunt encourages development of blood vessels within the liver and growth of the liver itself. These cases may also be treated with a cellophane band wrapped around the shunting vessel. This encourages gradual occlusion of the shunt by inducing a fibrous reaction around the vessel. Alternatively we would plan for a second surgical procedure at 3 months post-operatively. The majority of patients that did not tolerate initial complete ligation will go on to have a successful second surgery
  • Complete ligation possible – Complete ligation (tie off or closure) of the shunt vessel is desirable as it can result in complete resolution of the underlying condition

Please let us know if you have any additional questions or would like to speak to one of the specialists regarding a case.

Total Ear Canal Ablation (TECA) and Lateral Bulla Osteotomy (LBO)

What is a Total Ear Canal Ablation and lateral bulla osteotomy Surgery (TECA-LBO)?

Total Ear Canal Ablation (TECA) is a procedure performed to manage severe canal or middle ear disease in dogs.

Canine ear disease is a result of inflammation of the skin that lines the ear canal and can progress to infection within the middle ear. This skin inflammation may be part of a more generalised skin condition – some dogs may historically have issue with itching elsewhere in their body.

When to refer a case for TECA-LBO?

We typically reserve TECA-LBO surgery for patients that have severe “end-stage” ear disease that is no longer treatable with topical or systemic medical therapy.

Our approach:

To assess the extent of ear disease and middle ear involvement we will typically perform advanced imaging (CT or MRI) of the ears. If the extent of disease does not warrant surgery we will perform an ear flush, cytology, culture and otoscopy and review the underlying management strategies.

A TECA involves the removal of the diseased external ear canal. The middle ear or tympanic bulla is then entered by a lateral bulla osteotomy (LBO). This allows us to inspect the middle ear and remove abnormal tissue and the lining of the chamber.

What are the potential complications of surgery?

  • Hearing loss: Whilst TECA surgery does not involve the removal of the inner ear/hearing organ we do expect hearing loss for patient following surgery
  • Bleeding: There are some major blood vessels around the ear canal. All possible steps are taken to avoid these during surgery
  • Nerve Damage: The facial nerve runs very close to the ear canal. Surgery can occasionally (10-20% of cases) result in temporary paralysis of this nerve resulting in drooping of the eyelids and reduced ability to blink. The majority of these cases resolve in 1-2 months. Patients may also experience Horner’s syndrome or vestibular signs post-operatively. We have to closely monitor patients that develop neurological complications
  • Infection/abscess: Some cases can develop infections at the surgery site. Referral of cases for TECA-LBO surgery reduces this risk but in cases where infection occurs, further surgery may be warranted

Wound Management

Wound Management

All cases with complicated or problematic wounds referred to Hamilton Specialist Referrals are assessed by a Specialist in Soft Tissue Surgery. We work closely with our nursing team to create a plan for ongoing management of bandages and review this, as necessary.

When assessing wounds, we will assess the entire history of the patient and pay particular attention to any concurrent medical conditions that may affect the pet’s ability to heal or fight infection.

Assessment of the wound will allow us to tailor the management strategy for individual patients based on:

  • Extent and location of the wound/wounds
  • Chronicity of the wound
  • Presence of infection or neoplasia – sample (biopsies) may be taken for culture and histopathology if necessary
  • Previous treatments made prior to referral

There are various treatment options for wounds dependent on the information above but will often involve a combination of bandaging, second intention healing (natural healing that occurs when a wound is left without stitching it up), direct closure (suturing the wound closed), skin flaps (mobilization of local skin to cover the wound) or skin grafts.

In some cases we may elect to use a Negative Pressure Wound Therapy by placing a vacuum dressing over a wound. This specialized bandage can improve the healing of complicated wounds, whilst also protecting them from environmental contaminants. We will often utilize NPWT for skin grafts and large complicated wounds.

Complete healing and resolution can take time and become quite challenging. We often manage these cases closely with our referring vet colleagues. If you have a case that you would like to discuss please let us know – we would be happy to provide recommendations for management of difficult cases.

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