Transform your enucleation procedures from hour-long challenges to confident 15-20 minute surgeries. Dr. Josh Broadwater, DVM, DACVO, board-certified veterinary ophthalmologist with nearly 20 years of experience at Charlotte Animal Referral and Emergency in North Carolina, shares the revolutionary setup changes that make all the difference.
“Many general practitioners find enucleation surgery intimidating. My goal is to help veterinarians become more comfortable with this surgery while reducing both complications and surgical time.” – Dr. Josh Broadwater, DVM, DACVO*
The Enucleation Surgery Challenge
Many general practitioners find enucleation surgery intimidating. Dr. Broadwater frequently hears from colleagues who struggle with procedures lasting an hour or longer, often accompanied by excessive bleeding and complications. His refined approach addresses these exact pain points with three key changes we’ll cover in this series.
When Enucleation Surgery Is Necessary
Primary indications for eye removal surgery include:
- Intractable pain conditions: Ruptured corneas and advanced glaucoma in blind eyes
- Ocular malignancies: Tumors within or around the eye
- Severe orbital infections: Cases unresponsive to medical management
- Traumatic injuries: Including ocular proptosis (Dr. Broadwater notes seeing unusually high numbers recently)
Alternative Treatment Options Before Enucleation
Before proceeding with enucleation, discuss these permanent alternatives:
Ciliary Ablation (CBA)
- Injection of 20-30mg gentamicin into vitreous cavity
- 85-90% success rate for glaucoma cases
- Less invasive, lower cost due to minimal sedation
- Risk: 10-15% may develop phthisical eyes over time
- Not suitable if secondary glaucoma caused by potential malignancy
Intrascleral Prosthesis
- Removes internal eye structures while preserving cornea and sclera
- Maintains eye movement and blinking appearance
- Longer recovery period than enucleation
- Not ideal for cancer or infection cases
Revolutionary Setup Change: Dorsal Positioning for Veterinary Eye Surgery
The most critical modification Dr. Broadwater recommends is positioning patients in dorsal recumbency rather than sternal.
This single change can dramatically improve your surgical experience and outcomes. Most veterinarians are taught to position patients sternally, but Dr. Broadwater’s approach completely transforms the procedure.
Why Dorsal Positioning Changes Everything
Traditional sternal positioning creates multiple challenges:
- Limited surgeon visibility into the orbital cavity
- Awkward angles for instrument access
- Surgeon standing/leaning creates fatigue and less precise control
- Gravity works against hemostasis
Position Benefits for Enucleation Surgery:
- Patient’s nose points straight toward ceiling – optimal anatomical alignment
- Eyelids parallel to surgical table – eliminates gravity-related tissue retraction
- Surgeon seated for better control – reduces fatigue and improves precision
- Significantly improved access to orbital cavity – clear visualization of all structures
- Easier navigation of the deep orbital “cave” – instruments follow natural anatomy
Essential Equipment for Dorsal Positioning
Dr. Broadwater considers Vacuum Positioning Bags essential for consistent results. The vacuum bag allows you to mold perfect support around the patient’s body while maintaining precise head positioning.
Key features:
- Conforms to any patient size or body shape
Maintains position throughout entire procedure
Eliminates need for multiple repositioning breaks
Provides stable platform for delicate surgical work
Note from Dr. Broadwater: “I use Vacfix positioning bags, though they’ve become harder to find and more expensive. The investment is worth it for the consistency they provide.”
Sterilized Leashes for Large Dogs
For patients with longer noses that might shift during surgery, Dr. Broadwater recommends using sterilized leashes to secure the head position.
Application:
- Gently loop around muzzle area
- Secure to table to prevent movement
- Particularly important for breeds with elongated skulls
- Maintains precise anatomical alignment throughout surgery
Setup Protocol for Dorsal Positioning:
- Place vacuum bag on surgical table
- Position patient in dorsal recumbency with nose pointing to ceiling
- Mold vacuum bag around patient’s body for support
- Activate vacuum to lock position
- Secure head with sterilized leash if needed for larger dogs
- Verify eyelids are parallel to table surface
- Confirm comfortable surgeon seating position
Immediate Benefits You'll Notice
Veterinarians who switch to dorsal positioning report several immediate improvements:
Enhanced Visualization
The orbital cavity opens up like never before. Structures that were difficult to identify in sternal positioning become clearly visible, making the surgery more intuitive and educational.
Improved Instrument Control
Working with gravity instead of against it makes every movement more precise. Instruments follow natural anatomical curves rather than fighting awkward angles.
Reduced Surgeon Fatigue
Sitting comfortably instead of hunching over a sternally positioned patient reduces back strain and allows for steadier hands throughout the procedure.
Better Hemostasis
Gravity helps pool fluids away from the surgical site rather than obscuring your view, making bleeding control more manageable.
Implementation Tips for Your Practice
Dr. Broadwater offers essential tips for your practice, including:
Staff Training Requirements
Train your surgical team on the new positioning protocol before your first case. Practice the vacuum bag setup and head securing technique with a cooperative patient to work out any logistics.
Cost Considerations
While vacuum positioning bags represent an upfront investment, the time savings and reduced complications quickly justify the cost. Consider the value of cutting surgery time by 40+ minutes per procedure.
Getting Started
Dr. Broadwater recommends starting with straightforward cases to build confidence with the new positioning before tackling more complex enucleations.
Coming Up in This Series
Part 2: Essential Instruments & Surgical Technique – Discover the three specialized instruments that make enucleation surgery dramatically easier, plus Dr. Broadwater’s step-by-step surgical approach.
Part 3: Managing Bleeding & Preventing Complications – Learn advanced hemostatic control techniques using Vetigel® hemostatic gel and how to prevent the most common post-surgical complications.
The single change to dorsal positioning will transform your enucleation experience. Combined with the techniques in the next two parts of this series, you’ll have everything needed for confident 15-20 minute procedures.
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*Dr. Broadwater was paid by Zomedica, Inc. for his webinar presentation, which you can watch here.
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