Agricultural and Marine Sciences, 18:25-29 (2013) Sultan Qaboos University 25 ___________________________________________ *Corresponding author/E-mail: rramadan@kfu.edu.sa Surgery of the Dulaa in the Camel (Camelus dromedarius) Ramadan O. Ramadan Department of Clinical Studies, College of Veterinary Medicine and Animal Resources, King Faisal University, PO Box 1757, Kingdom of Saudi Arabia ABSTRACT: The present study was carried out on 45 native adult dromedary camels suffering from disorders of the dulaa. Clinical signs were those of dysphagia and or dyspnoea. Twenty-four camels (53.33%) were unable to inflate or extrude their dulaas. These signs were associated with pharyngeal swelling. Therefore the animals were examined radiographically. Fifteen (33.33%) camels suffered from collapsed and persistent protrusion of the dulaas. Four (8.9%) camels had previous episodes of dysfunction of the dulaa and the owner requested elective surgical excision. The remaining 2 (4.44%) animals had previous excision by healers and developed granulation tissue. Surgical management was achieved after light sedation using xylazine (2% Rompun, Bayer) supplemented with local infiltration analgesia or followed by induction of anaesthesia using ketamine hydrochloride (Ketamidore). The operations were carried out either through the oral cavity or following a pharyngostomy incision at the inter-mandibular region. In the latter instances, temporary tracheotomy was needed. The prevalent surgical affections were impaction with food material associated with ulcer or echymosis or abscesses. Less severe maladies were those of persistent protrusion accompanied with edema, haematoma, lacerations, small foci of abscesses and gangrene. The prognosis was favourable. The study included surgical anatomy, magnetic resonance imaging (MRI), as well as radiography of the dulaa in health and disease. Keywords: Dulaa, soft palate, dromedary camel surgery, MRI. اجلمال في اللهاة جراحة رمضان عمر رمضان في مرضية آفة فيصل بسبب امللك جلامعة البيطري التعليمي للمستشفى أدخلت اجلمال التي 45 من الدراسة على هذه أجريت اخلالصة: ثم اإلكلينيكي للفحص اجلمال هذه خضعت وقد البلع أو لصعوبة الطعام على تناول القدرة عدم إما للمستشفى التردد وكان سبب اللهاة. الفم. جتويف خارج الهدارة طرد او تستطيع الهدير ال (%53.33) جمال أن 24 الدراسة أوضحت احلاالت. بعض في السينية األشعة استخدام ملكانها الطبيعي تستطيع اجلمال إعادتها وال خارج الفم (%33.33) اجلمال من 15 هدارة احلنجرة. وكانت منطقة انتفاخ من تشكو كما كانت بواسطة بيطار الهدارة استئصال مت (%4.44) الفحول 2) من تبقى ( وما احليوان صاحب رغبة على بناء اجلمال (%18.9) من أربعة لهاة وأزيلت الرمبون مبهدئ احليوان تهدئة مت اللهاة تلبك حالة ففي املرض، نوع حسب اجلمال عالج ومت العالج. إعادة اجلراحة إلكمال الفحل وطلب صاحب البعير. صاحب رغبة حسب إزالتها ثم الهدارة وتفريغ اجلمل إدخال اليد داخل فم ومن ثم مناسبة (فاحتة فم) عكامة باستخدام الفم فتح ثم مت ذلك تعذر وإذا إزالتها. ثم اللهاة قاعدة عند املوضعي البنج تسريب ثم اجلمل تهدئة من متكننا فقد الفم خارج الهدارة موجودة كانت أما عندما السفلي الفك فرعي اجللد بني مت شق نفس اليوم في جراحية أخري عملية وفي القصبة الهوائية، الرغامي داخل األنبوب إدخال ثم اجلمل تخدير يسهل ومواد بسوائل اجلمل وتغذية الطيف عريض حيوي مبضاد احليوان حقن العملية اجلراحية وأعقب من قاعدتها. اللهاة استئصال ثم داخلها. وجود خراج أو اللهاة أو تهتك وتلبك واجلروح، الدموية، والقيلة والقرحة، الورمي، لتشمل خطورة األقل اللهاة إصابات وتنوعت هضمها. احلديثة. هذه التقنية حتت الرقبة ومنظر التشريحية بالنواحي لالستدالل على املرض املغناطيسي نافق بالرنني جمل ورقبة رأس دراسة مت وقد املقطعية - األشعة النام الواحد جمال ذات جراحة احللق , سقف كلمات مفتاحية: اللهاة، Introduction The dulaa is a unique diverticulum on the ventro-rostral part of the soft palate of the dromedary camel (Hegazi, 1949; Mukasa-Mugerwa, 1981). It is extruded from the bucal cavity during the rut or under excitation (Arnautovic and Abdel Magid, 1974; Wilson, 1988). A small minority of camels do not protrude the dulaa throughout their lifetime. The presence of dulaa outside the buccal cavity makes it vulnerable to trauma (Cross, 1917). Several reports describe the affections of the dulaa in Arabian camels (Bhargava, 1973; Vashishta et al., 1980; Gahlot, 1993; Ramadan, 1994; Barvalia et al., 1998; Rollefson et al., 2001; Gahlot et al., 2007). These reports have shown that minor ulcerations with subsequent flaccidity of the dulaa may lead to its impaction with feed (Ramadan and Abdin-Bey, 1987; Bolbol and 26 Ramadan 27 Surgery of the dulaa in the camel Shazly, 1992). Furthermore, neglected injuries may lead to gangrene of the organ with subsequent dysphagia and dyspnoea (Gahlot et al., 1988). Despite the importance of the dulaa, its radiographic findings, and surgical management is rarely documented (Ramadan, 1990; Ramadan, 1994). This review is intended to provide details of the clinical appearance of the dulaa and focus on its surgical management. Materials and Methods Clinical Animals A prospective study was performed of camels admitted to the Veterinary Teaching Hospital. Each camel was examined clinically and radiographs were taken on the lateral view whenever needed. Forty-five animals were subjected to surgical interference as follows: Group I: (=4; 8.90%) - Elective excision of dulaa; Group II: (=2; 4.33%) - Re-Excision of remnant of dulaa because the healer was unable to achieve complete excision; Group III: (=:15; 33.33%) - Animal was unable to return the dulaa back into the mouth. The dulaa was edematous, engorged, showing signs of haematoma and one case contained remnant of food particle. It was thus hanging at mouth commissure (Fig. 1); and Group IV (=24; 53.33%) - The animals were showing discomfort when swallowing; dysphagia, dyspnea were present and the animals were unable to extrude the dulaa (Fig 2). The reasons were lacerated wounds (5), gangrene (4), ulcers (7), abscesses (2) or impaction with feed material (6). Cadaver The head and neck of a 13-year-old male camel, which died for reasons not related with dulaa, was disarticulated at c3-c4.and subjected to MRI. Three dimensional pulse sequence were performed (T1-w; T2-w ; STIR) using a human 1.5 Tesla MR scanner. The stored plates were studied for understanding the imaging anatomy. Surgical Technique Elective excision The camel was secured on the sternal position. It was then sedated using 2% xylazine hydrochloride given intravenously at the dose of 0.2 mg/kg body weight. A further injection of ketamine hydrochloride was given at the dose of 0.5 mg/kg body weight. The mouth was widely opened using a Varnell mouth gag while the tongue was pulled through the interdental space. An assistant introduced his hand into the mouth in a cone manner to grasp the dulaa. Once in position, it was fixed with a long thread of non-absorbable suture material (Perlone no: 7 metric) to prevent it from accidental slipping. The dulaa was pulled as far as possible. The blood vessels were double clamped and cut between the clamps. Further pairs of haemostats were applied across the dulaa and the organ was cut between themusing a pair of surgical scissors. The stump of the dulaa was sutured using a No; 5 metric polyglactin 910 on atraumatic needle. The animal received a local and a systemic course of broad-spectrum antibiotics as well as a course of Vitamin K3. The owner was advised to feed the animal 5 liters of milk mixed with honey for one week. Figure 1. A camel protruding an impacted dulaa. Figure 2. A camel suffering from impaction of dulaa, note distended pharynx and extension of neck. 26 Ramadan 27 Surgery of the dulaa in the camel Excision of a dulaa hanging between mouth commissure The animal was secured in the sternal position and sedated with 2% xylazine hydrochloride (0.2 mg/kg body weight) together with 10% ketamine hydrochloride at the dose of 1 mg/kg body weight given intravenously. The dulaa was pulled as far as possible (Fig. 3). Local analgesic (2% lignocaine hydrochloride) was also injected at the base of the organ. The operation was completed as for the elective technique described above. Management of the Dulaa which Remains Inside the Pharynx Evacuation followed by excision of the dulaa The animal was sedated and provision of a temporary tracheotomy was undertaken by preparing the ventral part of the neck for an aseptic operation. A hand was gently introduced into the mouth as for elective procedure. The dulaa was pulled out and cleaned off any debris, thereafter resection was undertaken according to owner’s desire. When it was not possible to pull the dulaa outside the mouth, the animal was rolled to its side for pharyngostomy. Excision of the dulaa through the ventral part of the pharynx The animal was lightly sedated and the ventral part of the neck was approached aseptically. A 10 cm long skin incision was made at the level of the third cervical vertebrae. The incision was deepened by blunt dissection to expose the ventral cervical muscles. The fused bellies of the sternothyrohyiodeus muscle were separated. The trachea was pulled to the operative field and the annular ligament was incised. A temporary tracheotomy tube or a suitable endotracheal tube was inserted down the trachea. Now the ventral pharynx was prepared for an aseptic operation. A 15 cm long skin incision was made at the mid inter-mandibular space starting from the cricoids cartilage rostraly. The incision was continued below the belly of the left sternothyrohyiodeus. The muscle was retracted dorsally. The pharynx was thus entered. Care was exercised to avoid damaging the blood vessels. The hand was pushed rostrally to grasp the dulaa. The latter was primarily evacuated before resection (4 animals) or pulled out through the wound with its content and resected (Figs. 4 and 5). Results and Discussion Of primary interest in this study is the use of radiography for detection of pharyngeal lesions when the dulaa cannot be extruded by the animal. Radiographs illustrate the larynx, proximal trachea, esophagus, the naso and oropharynx but are unable to delineate a normal dulaa or a dulaa showing non-opaque lesion (Figs. 6 and 7). Under such a situation, the dulaa is collapsed and covered by the Figure 3. Excision of extruded dulaa. Figure 4. Ventral part of a camel pharynx during surgery. Figure 5. Ventral part of a camel pharynx after resection of dulaa. 28 Ramadan 29 Surgery of the dulaa in the camel vertical ramus of the mandible. Also subtle radiolucent lesions predisposing to dysphagia could not be diagnosed with certainty. However, when the dulaa was impacted with feed particles its size and density increases. It pushed caudally to press against the epiglottis thus interfering with breathing. Elective resection of the normal dulaa is not infrequently carried out by healers. Their technique is fraught with complications such as hemorrhage, infection or fibrous hyperplasia due to incomplete resection. The latter situation gave us an opportunity to re-excise the dulaa which was responsible for dysphagia and respiratory distress. The present investigation provides evidence that it is possible to treat affections of the dulaa through two surgical routes (the intra-oral and pharyngostomy incision). The intra-oral method is simple, less time consuming and does not subject the animal to the risk of general anaesthesia However, it may be applied to a severely impacted or indurate dulaa. Simple amputation has been attempted by some authors (M’zah et al., 1993; Ramadan, 1994). The main complication of the conventional surgical resection is post-operative bleeding and possible infection (Gahlot, 1988). Surgical resection showed drastic progress over the years and recently thermocautery provides quick and efficient amputation of the organ (Reece and Chawla, 2001). Persistent protrusion of the dulaa in most instances occurson its own (Cross, 1917; Ali, 1993; Gahlot, 1993), but in the present study, it was associated with impaction in one animal and with bilateral fracture of the mandible in two other camels. There have been questions raised concerning the inability of some camels to extrude their dulaa. In two animals studied by the present author, the dulaas were shorter and less elastic than normal. This may be a congenital anomaly. In the present study, disorders of the dulaa occur between the ages of 4-13 years (average 8 years). Other authors reported that injuries should never occur in camels less than 9 years (Dioli et al., 1992). Impaction, ulcers and abscess were observed more commonly in older animals. MRI is a useful modality, providing excellent image contrast and resolution that allows excellent visualization of anatomic details (Fig. 8). To date MRI studies are restricted to cadavers or newborn camels (Arincebia et al., 2005). Acknowledgments Thanks to my colleagues and house surgeons at the Veterinary Teaching Hospital, King Faisal University for their help during the study. References Ali, M.A., A.S. Saleh, and H.A. Yousef. 1993. Unexpected soft palate hanging in a dromedary.Assiut. Veterinary Medical Journal 28:272-276. Figure 6. 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Mundy, and E. Mathias. 2001. A Field Manual of Camel Diseases. ITDG Publishing, London, UK. Vashishta, M.S., R.P. Singh, and C. Kala. 1980. A rare abscess on pharyngeal surface of a camel. Livestock Advisor 5:68. Wilson, R.T. 1988. The Camel. London Longman House, Essex, U.K. Received: March 16, 2013 Accepted: December 3, 2013