for Improved Technique and Results
Q: Over the past 3-4 years I have done about 10-15
toggle suture LDA repairs, but I am not really satisfied
with the results? What can I do to become more successful?
Two factors might explain your situation. You might be placing
the suture in too far caudal or you might also be pulling
the sutures too tightly. Both factors can greatly influence
the outcome. It is also important to select your toggle
candidates well. Best results occur when the LDA is detected
and corrected early, as soon as she goes off feed.
Q: Over the years I have tied many toggle sutures
really tight, but a colleague told me that if I leave a
few fingers of space between the cow and the knots that
the cow will do much better. Is there any explanation for
Your colleague is right. Cows do better if the sutures are
pulled lightly, and adequate space is left between the knots
and the cow. The explanation is that the abomasum "floats"
easier to its normal anatomical position in the abdominal
cavity. Fibrous adhesions are formed around the sutures,
holding the abomasum in place.
Q: Sometime when I perform the toggle suture repair
I am confused because I can hear the abomasal 'ping' over
a large area when I have the cow in dorsal recumbency. Where
would you recommend that I place the toggle suture under
I insert the toggles in the cranial portion of the 'ping'
or at the recommended site for trocarization as described
in the Step-By-Step LDA Repair. The toggles will then be
placed in the greater curvature of the abomasum, which is
the correct anatomical position, and not too close to the
Q: I had a real problem today while attempting
a toggle suture repair. The first toggle went in very well,
but I just couldn't get the second toggle in and I couldn't
detect any abomasal gas. What should I do in this situation?
This is a difficult situation. It has also happened to us
over the years. If you can not get the second suture in
place, one option is to leave it in the abdominal cavity
as if it were tied in. Tie the two suture strings together
and you will still have the abomasum in place as a result
of the first suture. If you are uncomfortable with this
situation, then you have to cut the first suture, return
the cow to standing position, and then proceed with a flank
Q: Personally, I have great success with the toggle
suture method of LDA repair, and I don't treat my cows post
surgically with antibiotics? Do you think this is alright?
We always recommend postsurgical antibiotics, but we are
also aware that some practitioners do not follow these guidelines,
because they consider the procedure 'non-invasive'. We strongly
recommend postsurgical antibiotic treatment, however, it
really depends on the comfort level of the attending surgeon.
Q: Sometime when I do toggle suture repairs I have
a hard time getting the air flow out of the abomasum. Could
you please provide me with some explanation for this?
Some cows have very little gas in the abomasum, and even
when you apply pressure on the abdominal wall, the area
for trocarization is rather small. In these cows, only a
little gas will escape through the cannula. Another explanation
for no air flow is the skin plug which could block the cannula.
Occasionally, ingesta can block the cannula. Always keep
the push rod in the cannula when you penetrate the abdominal
Q: You might find this a silly question, but does
it matter which toggle suture you put in first, the anterior
or the posterior?
The first toggle suture should be the most posterior. When
the first suture is in place, it is easier to move forward
with the second suture because the trapped gas in the abomasum
'floats' upward and forward. Remember to apply pressure
in front of the udder to ensure the gas filled abomasum
Q: Sometime when I am doing the toggle procedure
the abomasal 'ping' will not move to the right position...right
side and anterior. Would you recommend that I do the toggle
suture procedure anyway if the 'ping' is to the left of
the midline, or very much posterior and on the right side?
In most cases you can move the cow from side to side and
get the 'ping' to be to the right of the midline. Try to
put a lot of pressure in front of the udder. You might even
let a person stand on the cow's belly to push the abomasum
forward. We have had cases where we have trocarized the
abomasum very caudal, and the cows have recovered satisfactorily.
However, it is better to place the first trocar perforation
in the correct anatomical location, 10-15 cm caudal and
4-6 cm to the right of the midline.
Q: What is the significance of letting the gas
off from the abomasum when you do the toggle repair?
Let the gas off after the second toggle suture is in place.
The significance is to try to minimize or to avoid the sutures
pulling on the abdominal, as well as the abomasal wall,
when the cow is allowed to stand. With a lot of gas accumulated
in the abomasum, the organ will float up higher and the
sutures will put pressure on the abomasal mucosa.
Q: I am a little reluctant to do a toggle suture
repair because I feel it takes too much help to get the
cow into dorsal recumbency. How many assistants are necessary
to safely perform this procedure...1 or 2 helpers, and do
you tranquilize the cow prior to treatment?
It is easier to perform this procedure if 2 persons are
helping, but for many practitioners, only one assistant
is necessary. If the cow is depressed, we never use a tranquilizer.
When tranquilization is given, we prefer to use 20-50 mg
of xylazine to sedate the cow. The decision to tranquilize
is often based on the disposition of the cow. The more fractious
she is, the more likely she is going to be a candidate for
Q: Why do toggle sutures work so well? Is it the
holding power of the sutures, or is it a result of local
peritonitis with adhesions holding the abomasum in place?
The sutures create small adhesions or ligaments between
the abomasum and the ventral abdominal wall, holding the
abomasum in its normal anatomical position.
Q: I have sometimes used a syringe case as a "stent"
over the sutures to help me gauge where to tie the two knots
together. Is using this type of "stent" a useful
Personally, I do not use a stent because I make sure that
I leave 8-10 cm of suture material before I tie the knot.
If you take care to evacuate as much abomasal gas as possible
before putting in the sutures and leave adequate suture
length before tying the knot, then you should not need to
use a stent. Some veterinarians find it helpful to use a
flat plastic button, or syringe case stent to distribute
the pressure on a wider area, so that pressure necrosis/abomasal
fistula does not develop. While I do not find it necessary
to use them in my LDA repairs, I would say that if you are
having success using this optional method of repair, then
you should definitely continue using this technique. At
the same time, I urge you not to ignore two important factors:
(1) remove as much abomasal gas prior to placing the sutures
and (2) leave adequate suture length, 8-10 cm before tying
the knots. The bottom line is to be successful.
13. Q: My problem on the farm is getting
help when we pull the cow down to perform the toggle suture
repair. 50% of the cows lie down on the right side and 50%
lie down on their left side. Can I just roll the cow into
dorsal recumbency from either side, or is it a must that
the cow should be on her right side and then rolled in a
clockwise manner to dorsal recumbency?
It is absolutely essential that you cast the cow on her
right side and then roll her to dorsal recumbency in a clockwise
manner. Otherwise the abomasum will not float to its normal
anatomical position and you will not be able to toggle the
Q: How sure can you be that you hit the abomasum
when toggling a cow? Could the air coming from the cannula
not be rumen or intestinal gas?
After performing very few abomasal surgeries you will know
the distinct smell of abomasal gas. If you are uncertain,
you can check the pH of the abomasal fluid by aspirating
some of the fluid with a catheter.