Flank or midline approach for female cat/dog spay?

Welcome to the world of spaying and neutering! February is officially recognized as Spay/Neuter Awareness Month, culminating in World Spay Day on the last Tuesday of the month. During this time, lots of amazing non-profit organizations, programs, and private vet clinics join forces to share valuable information and organize spay/neuter campaigns. Many of these efforts continue throughout the year, demonstrating an ongoing commitment to animal birth control. In India, the ABC programs began in the 1960s first by Blue Cross of India in then Madras.

One frequently asked question in the spay/neuter community is whether vets prefer the flank or midline approach for surgery and why. Historically, the lateral flank approach was more common in the earlier decades of animal birth control work in India. This preference was largely due to the ability to easily view the surgical site from afar, and because of the reduced risk of intestines falling out if there was a surgical site infection or wound dehiscence. Back then, surgical techniques and materials weren’t quite what they are today, leading to more post-operative complications.

Changing Times: Embracing Improved Standards

Fast forward to the last 15-20 years, and things have really evolved! With advancements in surgical standards and an increasing number of vets capable of performing midline abdominal surgeries, we have been seeing a shift toward the midline approach. With the increasing pet dog population and economic growth, the demand for more advanced surgeries to be performed on pet dogs has also increased and the private veterinary sector especially in big cities is growing rapidly. Many veterinary surgery skills development programs across India, like those offered by WVS India, prefer the midline technique because it allows better visibility of the abdomen for trainees and prepares them for a variety of abdominal surgeries—not just spays.

Interestingly, in the US, vets involved in feral cat management programs and animal shelters, have begun to show renewed interest in the flank spay approach in these programs  where really large numbers of cats are to be operated in a very cost-effective way.

My Take on the Matter

As you might expect, vets often have strong preferences regarding these methods, and I’m no different! Personally, I lean towards the midline approach because it’s versatile—suitable for pets of all sizes and ages, whether they’re healthy or have reproductive issues. It allows for safe sterilization under most circumstances and facilitates better management of any complications that may arise. However, I do recognize that the flank approach can be beneficial in certain situations. For example, if a cat is still nursing, the flank method minimizes disruption to the mammary glands, allowing for a smoother recovery for both the mom and her kittens.

Selecting Patients Wisely

One significant concern I have with the flank approach—especially for dogs—is the importance of proper patient selection. For instance, in cases involving pregnancy, pyometra, or obesity, the lateral flank incision might not be adequate to access the ovaries and uterus effectively, potentially leading to additional complications. If the incision has to be extended, most of the benefits of the flank approach are lost.

Another consideration is the risk of bleeding from the opposite ovarian pedicle. Given the limited space to manage any bleeding issues, the flank approach may carry a higher risk for post-operative hemorrhage if patient selection isn’t done carefully.

Weighing the Pros and Cons

When comparing different surgical techniques, we should do that only under equal skill levels and circumstances. For example, we shouldn’t compare a less experienced surgeon performing a spay on an obese pregnant dog from a flank incision with an experienced surgeon spaying a young, non-pregnant, ideal-weight dog from a midline incision. Both techniques can work beautifully for the right kind of patients and in the right hands!

Advantages of Flank Spay:

• Lower likelihood of evisceration if the body wall incision were to break.
• Easier to observe the incision from a distance.

Disadvantages of Flank Spay:

• Limited access to the opposite side to handle complications.
• Identifying previous spays can be tricky if the animal isn’t marked properly.
• Potential for uneven hair regrowth on the flank.

In summary, both the flank and midline approaches have their own sets of pros and cons. It’s all about choosing the right method for each individual case and following all the principles of good quality surgery (for example, tissue handling, asepsis, correct suture material selection) carefully. Whether you’re a vet, an animal advocate, or simply someone interested in learning more, there’s always room to discuss and share insights on the best ways to improve access to spay/neuter surgeries, to make them more easily available, affordable, and accessible for all dogs!

I am happy to share here a video by the Trichy Animal Birth Control center, showcasing their work in using the flank method. Their vets attended the WVS India surgery skills development program in Ooty in 2024. 

Celebrating the freedom to choose

To celebrate Spay Neuter Awareness Month and World Spay Day, as well as the freedom of vets to choose the method they feel most comfortable and confident for each specific patient, we have added Allis forceps to our selection on the Access to Vet Care -online store. Those who like to do flank approach spays can add the number of Allis forceps they want to the basic spay/neuter surgery instrument kit. Either to the cat or dog spay/neuter surgery kit. Those who prefer the midline approach can also finetune their incision placement skills to optimize it and then begin to reduce the length of the incision. Spayhook is a great companion for midline-approach surgeons as well because it can help to bring the ovaries and uterine horn out from a smaller incision.

Happy spaying!