Tortoise Bladder Stone

Introduction

One of the more interesting surgeries we perform is the removal of a bladder stone from California Desert Tortoises. Some of these stones grow to tremendous size, and it is a wonder that these animals can survive with such a problem.

沙漠地鼠陸龜的膀胱結石摘除手術是滿有意思的外科手術.有些膀胱結石簡直是大到不行,真不知道那些 龜龜是怎麼活下來的.

Symptoms 徵狀

There are no specific symptoms that tell us a tortoise has a bladder stone, some of them don't show any symptoms at all. The more common symptoms are nasal discharge, poor appetite, and lethargy. Some of these stones are diagnosed as incidental findings when we take an x-ray or perform an exam for an unrelated problem. The tremendous size of some of the stones indicates they may have been present for years before being diagnosed. Anybody that has ever had a kidney stone can sympathize with what these animals feel like with such large stones.

陸龜罹患膀胱結石並沒有明顯的徵狀,有些龜龜更是完全沒有徵狀.比較常見的徵狀是流鼻涕,食慾不佳以及昏睡.有些結石是龜龜因為其他毛病照X光或是檢查而意外發現的.有些結石體積巨大,可見在診斷出來的時候已經在體內存在好 多年了.得過腎結石的人就可以體會到這些患有大結石的龜龜會有什麼樣的感受.

 Diagnosis 診斷

There are two methods utilized to diagnose bladder stones. During an examination we can sometimes palpate a stone by gently rolling the tortoise back and forth while we feel in the soft spot by its rear leg.

診斷陸龜膀胱結石的方式有兩種,輕輕前後搖動龜龜,有時候可以由後腿根部柔軟的地方觸診到結石.

To perform the palpation technique you need to understand tortoise anatomy and be experienced at palpation.

要執行觸診必須要對龜龜的生理構造有所了解

而且也必須具有觸診的經驗.

---

Not every stone can be found on palpation. The other method to make a diagnosis, and usually more reliable method, is to take an x-ray. Even though the stone in this x-ray is large, this is not an unusual finding. Some of the stones are so large that we have to break them into pieces to get them out of the opening in the shell.

但是並非所有的結石都能經由觸診來發現,

另一個診斷方式,也是比較可靠的方式,

當然就是照X光了.雖然X光片中這顆結石很大,

不過並不罕見,有些結石甚至大到需要先擊碎

才能由腹甲的切口夾出來.

Surgical Procedure 手術程序

The usual treatment for a bladder stone in tortoises is to perform surgery. In this surgery we literally cut a hole in the bottom of the shell and remove the stone from the bladder. Most tortoises do fine postoperatively, and after a few days in the hospital and a few weeks of recuperation at home, they are back to normal.

陸龜膀胱結石一般的治療方式就是外科手術.再這次手術中我們就在龜龜的腹甲上開個切口,然後把結石從膀胱夾出來.

Prior to surgery our patient is prepared to minimize anesthetic risk. In some patients we place a feeding tube to insure adequate hydration and nutrition, both before and after the surgery. In other patients we insert an intravenous catheter (IV) to maintain blood pressure during surgery.

在手術之前病龜先做最好準備,讓麻醉的風險降到最低.有些病龜在手術之前和手術之後我們都會插餵食管補充水份和營養劑.有些病龜我們則是插靜脈導管以維持手術中的血壓 的穩定.

This tortoise has an IV catheter in its jugulare vein. We use this vein because it is relatively easy to insert the catheter and it is large enough to take the volume of fluid we need to give.

這隻龜的頸靜脈插了靜脈導管.我們插這條靜脈主要是

因為它比較粗,比較容易插管,也比較可以容納我們

必須注射的液體劑量.

---

After the tortoise is anesthetized the bottom of the shell (called the plastron) is cleansed thoroughly. This may take several scrubbings with the use of a gentle brush to get clean enough for surgery. The black rectangle outlines where the shell will eventually be cut to gain access to the bladder.

---

As in any surgery we perform controlling infection is critical. We use a specific draping technique to minimize the chance of infection. Infection is especially critical in this surgery because once the cut piece of shell is resealed to the bottom of the shell, an infection can fester on the inside without our knowing about it.

---

The rest of the surgical team is preparing at the same time. These assistants are students in our externship program. They will be assisting the surgeon with flushing and suctioning of fluids, along with the administration of anesthesia.

手術小組的其他人員也要同時準備,這些助理都是校外

實習醫生,他們會協助醫師進行液體的沖洗與吸淨

以及麻醉.

---

Dr. Ridgeway starts his cut with his safety glasses on to protect him from particles brought on by the drill used to cut into the shell.

Ridgeway醫師戴上安全眼鏡進行切殼,以免被

鑽頭帶出的碎片傷到.

---

A sterilized dremel is used to cut through the shell. The blade spins at a high speed so sterile water needs to be constantly applied to the cut surface to minimize burning. The blade cuts at an angle facilitating replacement of the shell when the surgery is complete. If this angled cut is not made, the shell will just fall back into the abdominal cavity (it is called the coelomic cavity in a reptile) and the incision site will never heal.

鋸開腹甲是用消毒過的電鋸,由於鋸片高速旋轉會產生高溫,所以必須持續對切口噴灑無菌水以避免燙傷

---

When the shell has been cut in a rectangular piece it is gently pried up with an instrument called an elevator. There are muscular attachments that are gently separated from the shell to allow the shell to become completely free. The cut shell is living tissue and needs careful handling. After it is removed it is kept moist with sterile saline until it is replaced at the end of the surgery.

當腹甲四邊都切開之後,就用一種稱為撬起器的工具

把甲片撬起,再輕輕切斷連在甲片下的肌肉組織,

讓甲片完全脫離腹甲.切下的甲片還是活體組織,必須

小心處理,要用無菌鹽水保持濕潤直到再裝回去為止.

---

The next layer encountered is the lining of the coelomic cavity. It is gently cut to give full exposure to the organs in the cavity. The reddish areas are the muscular attachments to the piece of shell that was removed.

再來就會看到體腔覆膜,輕輕把它剪開露出下面的器官,

切口四周的紅色的部份就是原來連住甲片的肌肉組織

---

Internal organs can be visualized easily through this large opening. These are loops of intestines.

體腔覆膜切開後就可以輕易看到裡面的內臟.

圖中看到的是腸道.

---

The bladder is gently exteriorized through the hole in the shell. Dr. Ridgeway has made an incision into the bladder and the stone is starting to bulge out.

小心的把膀胱由腹甲切口中提出來,Ridgeway醫師

已經在膀胱上做了一個切口,露出了結石

---

Here is the culprit as it is being removed from the bladder. 

這就是整個挖出來的結石

---

The bladder is usually filled with a sludge like material. If the sludge is not removed healing will be delayed and the potential for recurrence of the stone increases. The larger clumps of sludge are removed with a special instrument called an angle spoon. This high tech instrument is made special in our lab by taking a regular tablespoon and bending it.

膀胱中通常還會積有一些淤渣,如果沒有一起清除,

就會減緩復原的速度,而且結石容易再復發.這一團

淤渣是用一種稱為角匙的工具挖出.這種高級工具

是在我們的實驗室中用一般的湯匙拗彎做成的.

---

The smaller pieces are suctioned after the bladder has been flushed. This usually takes many flushings with sterile saline. Only when the bladder has been thoroughly flushed is it sutured back together.

較小的淤渣就在膀胱清洗完後連水一起吸掉,通常

要用無菌鹽水清洗幾次才能洗乾淨,膀胱一定要

完全清洗乾淨後才能縫合.

---

A special suture material is used to close the opening in the bladder. This suture is very strong yet causes minimal tissue reaction, and will slowly dissolve over several months.

用於縫合膀胱切口的是一種特殊的縫合材料.

很堅韌又不會引起排斥,而且在幾個月後

就可以完全被吸收

---

The coelomic cavity is also flushed copiously with warm sterile saline, then the fluid is suctioned out. This process helps prevent an infection and aids in the healing process. If an infection is sealed into the coelomic cavity the outcome could be catastrophic.

體腔一樣要用無菌溫鹽水徹底清洗,水份要完全吸乾,

這個程序有助於防止發炎並加速癒合.萬一把感染

封在體內那後果就不堪設想了.

---

The incision made in the tissue lining the cavity is sutured next, using the same type of suture material as the bladder. The muscular attachments to the cut piece of shell will gradually reestablish themselves to the underside of the cut piece.

再來就是縫合體腔覆膜的切口,當然也是用縫合膀胱一樣

的線材,連接甲片的肌肉組織會自行逐步再連住甲片

---

While all of this was going on the piece of shell that was removed at the beginning of the surgery was kept moist by wrapping it with sterile gauze soaked with saline. Doctor R is removing the gauze before putting the cut piece of shell back in place.

在手術過程中,切下的甲片一直是用泡過鹽水的無菌沙布包著

Now the fun of putting the shell back together begins. The previously removed piece of shell is put back into position and a piece of fiberglass is measured and cut so that it just covers the cut piece of shell.

接著,復原甲片的樂趣就開始了.把切下的甲片蓋回去,

然後再裁切一塊可以完全蓋住甲片的玻璃纖維片.

---

A special quick drying epoxy is poured on the shell. Once this epoxy hardens it can not be removed or reshaped, so we have to move fast.

先擠一團環氧樹脂到腹甲上,這種快乾膠硬化

之後就無法再塑型或清除,所以動作要很迅速

---

It is spread evenly over the cut piece by two assistants. When it gets tacky we are ready for the next step.

環氧樹脂由兩位助手均勻的舖平在蓋好切口的腹甲上,

當樹脂快乾的時候我們已經準備好下一步了

---

The fiberglass piece is placed over the sticky epoxy and another layer of epoxy is poured over the fiberglass and rapidly smoothed over the fiberglass.

把裁好的玻璃纖維覆蓋在環氧樹脂上,然後再均勻的在

玻璃纖維上抹上另一層環氧樹脂

---

The epoxy becomes firm within a few minutes. During this time it is important that the tortoise does not wake up or breathe deeply because the pressure in the lungs will push the patch out.

環氧樹脂在幾分鐘之內就會硬化,這時不能讓龜龜醒來

或是用力呼吸,否則肺臟的壓力會把傷口擠開

---

Cellophane is put over the patch as it dries for cleanliness and protection purposes

最後再覆蓋上賽璐玢玻璃紙以保持清潔並保護傷口

---

Here is our friend just waking up from anesthesia. At this point we will give her a pain injection and place her in a special room that maintains a temperature of 85 degrees. She will stay in the hospital for a few days until she is eating and active.

這就是剛由麻醉中甦醒的龜朋友,這時我們會給牠打止痛針,

再把牠移入一間恆溫85度F的房間恢復,牠會住院幾天直到

開始進食和活動為止

---