Standing surgery is becoming ever more popular as facilities and expertise improve. Surgical procedures that have always traditionally been performed under general anaesthesia, can now be performed routinely on the standing sedated horse with regional and local anaesthesia. The accompanying article on standing upper airway surgery describes the range of surgical procedures that are performed standing and explains some of the advantages, as well as other procedures such as laparoscopy, fracture repair and some arthroscopies that can be readily performed with the horse standing. The advent of new instruments such as needle arthroscopes, oroscopes and better imaging techniques such as computed tompgraphy and magnetic resonance imaging allow for more accurate diagnoses and better visualisation, which further facilitate standing surgery. The main advantage is clear, in that general anaes-thesia in horses is a risky procedure and if this can be avoided then that has to be a good thing, but it is important to consider - at what cost does this come?
Standing surgery of any type requires a higher level of skill, knowledge, confidence, and bravery. It requires significant investment in facilities and staff and these things should be reflected in the charges. Frequently, I hear that because a procedure is performed standing and not under general anaesthesia it should be cheaper. I would argue against this, as the advantages are all conferred to the patient and the client and such, in my professional opinion, these factors should generate a higher charge. In fact, one could reasonably argue that because a procedure is being performed in the standing sedated horse then a premium should be applied – as surely the attending veterinary surgeon and their practice should benefit from a greater profit for that procedure?
It is also fair to say that in some procedures the anatomy is easier to navigate with the horse standing up, as it is in a more natural orientation which can facilitate a procedure. As outlined in the accompanying article, a number of upper airway procedures are actually easier and better performed with the horse standing.
As a profession, we have seen the same situation with dental procedures and laparoscopy, to the point where it is now absolutely routine to perform these procedures in the standing sedated horse. When performing a laryngoplasty in the standing sedated horse, the ability to have an endoscope in situ without an endotracheal tube obfuscating your view of the larynx allows for more accurate and considered assessment of the degree of abduction being obtained.
In a similar vein, the ability to repair a simple lateral condylar fracture with the limb weight bearing and in a ‘natural alignment’ allows for very accurate screw placement, as well as removing the risk associated with additional stress and load being placed on the implants during recovery from general anaesthesia. These are examples of genuine advantages that enhance these procedures whenthey are performed in the standing sedated horse, compared with performing them under general anaesthesia.
If the primary advantage of standing surgery is to avoid the risks of general anaesthesia, and this is clear cut, then the primary disadvantage of standing surgery is equally as obvious - it is dangerous. The risk of personal injury to the surgeon and the people assisting is much greater than when the horse has the same procedure performed under general anaesthesia. This point is not to be underestimated and any surgeon who performs any amount of standing surgery on horses will have experienced this and know that it can be very serious.
As a result, consideration must be given to wearing personal protective equipment such as a helmet and extreme care must be taken to mitigate the risks in situations where this can occur. This very much comes down to experience of the team performing the procedure and also the facilities available. Performing standing surgery, in my opinion, should be considered a progressive advancement and evolution of a surgical procedure, which requires investment in facilities and instrumentation to ensure it is safe to perform.
Although, a less obvious but important disadvantage of standing surgery is sterility. Whilst every effort is taken to maintain asepsis, it is much harder to achieve this. Draping is more challenging and even the most obliging of patients will move to a degree under standing sedation. Of course, there are also those moments where large movements occur and lead to significant contamination of the surgical field. This may lead to an increased risk of complications or the need for more prolonged antibiotic administration, both of which are things that veterinary professionals would generally rather see less of.
In short, standing surgery of any type is not necessarily the solution to all of the problems that we encounter as equine surgeons. However, there are situations where it is clearly advantageous and we should endeavour to seek all of the advantages that we can when performing surgery on horses.
It is my belief that when considering standing surgery in horses that we must ensure that the increased risk to ourselves and our team is compensated for, especially when one considers the advantages conferred to the horse and subsequently the owner, as well as the increased skill set, experience and facilities required to make standing surgical procedures a success.