Caudectomy in the ER

In this article Lee Herold, DVM, DACVECC, summarizes the caudectomy procedure (tail amputation) and gives her procedural pearls of wisdom from years of experience.

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In the emergency room, we often encounter tail injuries that require caudectomy, or tail amputation. Trauma is the most common reason for caudectomy in the ER. Skin and soft tissue wounds, including severe bite or animal wounds, de-gloving injuries secondary to motor vehicle trauma or secondary to a tail being shut in a doorway, are the more common indications for caudectomy seen in ER practice. Strangulation injury is a less common reason for tail amputation but can occur. Strangulation injury usually occurs when owners with good intentions bandage small wounds on the distal tail but inadvertently bandage too tightly and produce a tourniquet effect resulting in tissue death distal to the bandage (Figure 1). Any cause of repeated self-trauma to the tail, such as pruritus or infection, may necessitate tail amputation. Severe tail fractures or luxation injuries, which result in absent sensory and motor function to the tail, may be an indication for caudectomy even if there is no skin defect. With mild caudal subluxations, caudectomy may be postponed in favor of waiting one to two weeks to see if there is any return of neurologic function to the tail to avoid unnecessary caudectomy. Removal of tail masses may be an indication for caudectomy if there isn’t enough skin for closure after removal of the mass. In our ER, caudectomy for removal of tail masses is usually not performed given the elective nature of most mass removals, with the exception of a patient who is severely self-traumatizing.

Figure 1: Before and after – left is a picture of the tail of a patient who sustained distal ischemic tail injury because the clients had bandaged a tail abrasion for several days prior to presentation. Right is a picture of the remaining tail immediately after caudectomy.

Many available surgical texts provide detailed and descriptive step-by-step procedures for caudectomy. Here, I will present only a summary but will comment on important procedural pearls to think about in surgical planning. Caudectomy involves making two V-shaped skin incisions that meet to make a dorsal and ventral skin flap, ligation of the lateral and median vascular bundles, transection of the tail via disarticulation between caudal vertebral segments, and subsequent closure of soft tissue and skin over the exposed and remaining caudal vertebra to finish the procedure.

SURGICAL PLANNING TIPS

Caudal anesthesia/analgesia

  • Caudectomies are performed under general anesthesia; however, surgery in this location provides an excellent opportunity to perform local anesthesia to augment postsurgical pain control and reduce the risk of self-trauma post procedure. Anesthesia of the tail can be achieved by standard L7-S1 epidural injection with local anesthetics or with the technically easier to place sacral-coccygeal or inter caudal blocks.

Ensuring a clean surgical field

  • In the ER, we are usually performing caudectomy for cutaneous trauma or wounds. To keep the broken skin and traumatized tissue shielded from the surgical field, but still have access to the tail during the procedure, remember to drape the exposed distal tail in addition to the actual surgical site. Draping the traumatized distal tail can be achieved by wrapping the tail with sterile vet wrap or wrapping it with a sterile paper drape/huck towels secured with towel clamps if sterile vet wrap is not available. If you are performing a very distal amputation, the tail tip can be placed inside a sterile glove, which will also effectively shield it from your field.
  • If a very proximal caudectomy is being performed, remember to place a temporary purse-string suture in the anal opening to avoid fecal contamination of the surgical site. When placing a purse-string suture, always have the anesthetist make a visual note or checklist on the anesthesia sheet to remind you to remove the suture after the procedure is completed.

Tourniquet application

  • During tail amputation, a tourniquet is applied proximally to the tail to reduce hemorrhaging and improve visualization, providing for easier identification of the vascular bundles for ligation and ultimately reducing surgical time. Loosely place the tourniquet on the proximal tail, then prep and drape the surgical site with the tourniquet outside of the surgical field (Figure 2).
  • There is no consensus on the maximum time a tourniquet can be applied without resulting in ischemic injury, but minimizing the time of tourniquet application is intuitive. I will have the anesthetist tighten the tourniquet after I have made my initial skin incision. With the tourniquet applied, I will proceed with the dissection and identification of vascular bundles. As soon as vascular bundles are ligated, I will have the anesthetist release the tourniquet, and then I will proceed with disarticulation and closure. Depending on the surgeon, this will result in a total tourniquet application time of 10 to 20 minutes within a total surgical time of 30 to 60 minutes.

Figure 2: A tourniquet is very loosely placed on the tail base but not activated/tightened. When fully draped, the tourniquet will be located outside the surgical field. A non-sterile assistant or anesthetist can be enlisted to tighten the tourniquet when the surgeon is at the appropriate place in the dissection, thus minimizing the time of tissue ischemia from the tourniquet.

Where to locate the caudectomy

  • The purpose of the V-shaped incision is both to provide enough skin and tissue to close over exposed vertebra without tension and to provide a cosmetic closure that approximates the natural taper of the tail. To ensure healthy skin for closure, locate your incision with a margin of least 2-3 cm of healthy skin distal to the incision if possible.
  • Place your V-incisions at least 1 cm distal to the proposed intervertebral disarticulation site. It is better to trim back the skin flaps for closure rather than have too little skin resulting in tension on your closure (Figure 3).

Figure 3: Picture of the removed segment of a tail. Notice how much of the vertebra is exposed. This demonstrates the principal of locating the tail incision in a position to ensure that a generous amount of skin is left to provide for a tension-free closure.

Caudectomies can be rewarding procedures with high rates of success, though some of the success relies on post-op home care. Preventing the pet from access to the surgical site is essential post-op. E-collars are mandatory in patients undergoing caudectomy. In dogs, if the caudectomy is distal enough that the patient can traumatize the surgery site from tail wagging, then careful and protective bandaging of the tail may be required in the first week post-op.

For many of our clients, the prospect of their pet losing a large or even small portion of their tail is quite traumatic. The tail does not serve a vital function, but when treating these patients, it is worthwhile to take the time to acknowledge the value that tails provide in allowing the pet to express their state of mind and thus bond to the owner. Redirecting the client’s focus to great success rates, with near 100 percent return to quality of life, while also empathizing with their fears, will ease their reservations about this procedure when it is required.

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