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A groundbreaking surgical technique created by Sydney-based vet Dr Sam Kovac provides minimally invasive treatment for brachycephalic airway syndrome in dogs. By Frank Leggett
Boxers, bulldogs, Cavalier King Charles spaniels, Pekingese, pugs—the list of brachycephalic dog breeds is long, wide and varied. Unfortunately, due to the unique shape of their faces, breathing difficulty is a common problem with these types of dogs. The worst affected individuals can have a significant risk of heat stroke and sudden death.
Traditionally, surgery is the most common way to rectify the issue, but the technique is invasive, lengthy and risky. One veterinary surgeon, Dr Sam Kovac, believed there must be a better way to help these dogs. And so, he invented a whole new procedure to treat the problem.
Inner city vet
Born and bred in the inner city of Sydney, Dr Kovac always wanted to own a practice close to his family. In 2012, six months after graduating from the University of Sydney, he opened his first clinic, Southern Cross Vet in the Sydney suburb of St Peters. With an unbridled passion for veterinary work and a commitment to positive outcomes, he managed to rapidly expand the business. Today, Southern Cross Vet has branches in three Sydney locations—St Peters, Surry Hills and Bellevue Hill. Being located in such high-density areas means that the clinics see a raft of dog breeds popular among inner-city residents.
“The most popular breed is oodles,” says Dr Kovac. “Brachys are our second most popular breed and at present, we have around 2000 of them on our books. French bulldogs, pugs, Boston terriers, Griffons—we see them all.”
Dealing with so many brachycephalic dogs meant that Dr Kovac was frequently undertaking surgery to correct brachycephalic airway syndrome. The traditional surgical technique was traumatic, causing significant bruising and swelling, and sometimes requiring a tracheostomy tube, followed by intensive care in an oxygen cage.
“I knew there must be a less invasive way to do the operation,” says Dr Kovac. “The procedure needed to be less risky and the recovery easier. If I could find a way to make the surgery routine and preventative, it would allow for a paradigm shift among vets and owners. Ideally, the procedure should be proactive and undertaken before the dog ends up with breathing issues.”
Seeing and treating so many of these dogs, Dr Kovac soon realised he was also dealing with an ethical issue. He firmly believes that all veterinarians have a commitment to treat all dogs that are suffering. There are other people, however, who believe that the breeding of brachycephalic dogs is cruel and should be banned.
“I was frequently criticised for my position,” Dr Kovac says. “Some people think that normalising the breathing of these dogs through surgery is the wrong thing to do. They want owners to see their dogs suffer, so they won’t choose to get another brachy in the future. It’s an absolutely ludicrous suggestion.”
This school of thought believes that breeding brachycephalic dogs should be banned as the dogs are purposely deformed. While Dr Kovac doesn’t support a ban, he would like to see the Australian Veterinary Association and other animal organisations encourage breeders to modify the breed standard so brachys have longer snouts and less breathing issues.
“People buy these dogs for their quirky, awesome personalities, and their appearance,” he says. “That demand is not going to go away any time soon.”
On the other hand, Dr Kovac does support the banning of some dog breeds. He has voiced a very public opinion urging the restriction of American Staffordshire terriers to only be bred by authorised breeders. Furthermore, he believes they should only be owned by people who have experience with the breed and a commitment to training.
“This breed is associated with more lethal dog attacks—anecdotally and on the record—than any other,” he says. “They are also the number one euthanised breed in shelters. By stopping the widespread ownership of this breed, we could improve animal welfare. Anyone who loves dogs will agree with me if they can put aside the ‘deed not breed’ concept, and an egalitarian approach to dog breeds.”
Traditionally, brachycephalic airway surgery saw the soft palate clamped and crushed, causing extensive bruising. It was then cut and multiple stitches placed at the back of the throat. This acted as a foreign body which causes scar tissue to develop. The procedure takes at least 40 minutes, even in the hands of an experienced surgeon.
Instead of clamping the distal portion of the soft palate and cutting with a scalpel, Dr Kovac’s technique uses an electrosurgical handpiece to seal and cut the palate in one action, shortening it at the same time. It’s much faster, reducing the procedure from 40 minutes to about 15 seconds. There’s much less bruising and swelling, with a lower anaesthetic risk and a reduced chance of an obstruction post-operatively.
“In the past, staphylectomy was performed using crushing haemostats and a blade or sharp implement to amputate the soft palate,” he explains. “When electrocautery came along as an option, it was an improvement, but still caused necrosis and inflammation—because you’re still burning tissue. C02 lasers were an improvement again. At the end of the 1990’s, advances in computing began to make Energy Based Vessel Sealing Devices (ESVs) a more viable option.
“Unfortunately, many vets still aren’t familiar with Caiman-esque radiofrequency devices and lump them into the same category as ‘cautery’ and ‘laser’, and indeed there are vast differences between all the options available. These ESVs seal collagen using precise microwave technology at a low temperature, causing no charring. It is genuinely a minimally invasive approach which cannot be said for other methods. Ligasure is the original device, developed in 1998. Since then, the Caiman was released as a further refinement causing less thermal spread and necrosis and inflammation than others.
“Moreover, the technique developed and used by us isn’t limited to just the use of the handpiece. It is a suite of steps that happens during the operation that is contained within the patent I own on this technique—the technique is so unique, that we have a current patent on it, which speaks for itself.”
Dr Kovac has offered to share the patent as a PDF with any veterinarians who get in touch with him and request it.
“In the beginning, I performed the procedure on cadavers to make sure I fine-tuned the angles of the soft palate resection,” says Dr Kovac. “Using the cadavers allowed me to correct issues with frying the tips of the larynx. I soon overcame the challenges of the device until the procedure was very straightforward.”
Since then, Dr Kovac has added a few modifications to the technique including more local anaesthetic, applying mannitol and bupivacaine-soaked swabs to pack the back of the throat to reduce swelling and pain, encouraging an anaesthetist to be present, monitoring patients overnight, and improved consent forms and a consent process.
Applying the new technique
While Dr Kovac’s new technique offers many benefits to patients and clients, one drawback is that the equipment set-up is costly. This can be a barrier for some vets.
The procedure is popular in his clinics and has a 95 per cent satisfaction rate with his clients.
“The only times we really have pushback is when the nose discolours to pink for a few months,” he says. “In some cases, this happens post-operatively as the inflammation affects pigmentation. Despite this, the procedure is routine in all my clinics now. We have moved on from the experimental phase to offer this as our standard of care.”
With such positive results from this minimally invasive technique, Dr Kovac has had clients travel to his clinic from all over NSW. His first patient from Queensland is booked for later this year.
“There’s a vet in Victoria using the technique and many specialists and surgeons are now using a CO2 laser to perform airway surgery,” he says. “We’re doing around 200 of these surgeries per year. Word has certainly been spread by happy clients delighted with the outcome in their pets.”
Dr Kovac attributes the success of his Southern Cross Vet clinics squarely to his team. He has focused on creating a business culture of positivity and happiness, and those who like to gossip or bully are swiftly ejected from the organisation. His new technique to help brachycephalic dogs has been a great success. This stems from the whole team’s passion and ambition to improve the lives of companion animals.
“Right now, I’m very satisfied with where we are as a business and a practice,” says Dr Kovac. “At the same time, I plan to continue growing Southern Cross Vet to more sites in Sydney, as well as looking for opportunities to expand into other states. I know it sounds cheesy, but the core of everything we do is the patient. There’s no doubt in my mind that the main reason for our success is due to our role as vets and nurses, advocating for the patient.”