gastrointestinal veterinary talk, part 2
DESCRIPTION
"Abdominal Exploration-When to cut, anatomic review and surgical techniques" Presented by Dr. Earl (Trey) F. Calfee, III Form more information about nashville Veterinary Specialists and Animal Emergency services, please visit our website at http://www.nashvillevetspecialists.comTRANSCRIPT
Anatomic reviewImportant anatomic points
and helpful hintsVasculatureGastric cardia – palpation
of stomach tubeFundus – greater
curvature area of necrosisAntrum – location of
gastropexy incisionPylorus I.D. by decrease
in luminal diameter more than palpation
Gastric wall – “slipping membranes”
Anatomic reviewProximal duodenum
Duodenal papillaMajor – bile duct
and pancreatic duct
Minor – accessory pancreatic duct
Anatomic reviewProximal duodenum
Duodenal papillaMajor – bile duct
and pancreatic ductMinor – accessory
pancreatic duct
Anatomic reviewProximal duodenum
Duodenal papillaMajor – bile duct
and pancreatic ductMinor – accessory
pancreatic duct
Anatomic reviewDuodenocolic ligament
Holds distal descending duodenum to dorsal body wall
Challenge to running bowel
Easily transected if needed
Difficult to suture adjacent duodenum if not transected
Anatomic Review
Full abdominal exploration - “Open them up”
Be systematicBe gentle especially
with linear foreign body
Systematic Exploration
My approachLiverStomachDuodenum and right
pancreatic limbRight kidney and adrenal Jejunum, Ileum and ColonLeft kidney and adrenalBladder+/- Gall bladder
expression+/- Opening omental
bursa and left pancreatic limb
Systematic Exploration
Surgical optionsGastrotomyGastropexyGastrectomyGastric resection
anastomosis
Gastric surgical techniques
Gastric surgical techniquesGastrotomy
Location – ventral surface equidistance from greater and lesser curvature
Gastric surgical techniquesGastrotomy
Minimize contaminationPack off abdomenStay suturesSuction helpfulTowel ready to
receive what comes out
Orogastric tube prior to entering lumen if fluid filled
Gastric surgical techniquesGastrotomy
Minimize contaminationPack off abdomenStay suturesSuction helpfulTowel ready to
receive what comes out
Orogastric tube prior to enter lumen if fluid filled
Gastric surgical techniquesGastrotomy
Stab incisionExtend with scissors
parallel to curvatures
Separation of layersMucosa-submucosa Muscularis-serosa
Gastric surgical techniquesGastrotomy
Single or double layer closureI typically close in
two layers using 3-0 PDS Mucosa-submucosa –
simple continuous Serosa-muscularis –
interrupted lembertNo leak testThe stomach wants
to heal
Gastric surgical techniquesGastropexy
LocationTechnique
I only perform incisional
2-4 cm from pylorusVentral midpoint of
antrumAvoid lumen
penetrationSeparation of layers+/- stay sutures
Gastric surgical techniquesGastropexy
LocationTechnique
Be aware of diaphragm = pneumothorax
Glistening fascia Transverse incision not
too dorsal Suture deepest to most
superficial2-0 PDS two continuous
strands joined at most ventral aspect of pexy
Avoid lumen penetration
Gastric surgical techniquesGastrectomy
IndicationsNecrosis - GDVNeoplasiaUlcer with
perforationRupture
Gastric surgical techniquesGastrectomy
Gastric viabilityColor
Gray = badPurple = likely OKRed = good
ThicknessTemperatureBleeding on cut
serosal surface
Gastric surgical techniquesGastrectomy
TechniqueStapled – TA or GIACut and sew, cut and
sew, etc.Lots of stay suturesTechnically challenging
Contamination Tissue thickness in
intestinal forcepsInvagination
Serosa to serosa healing
EasyNo contamination
Gastric surgical techniquesGastric R-A
IndicationsNeoplasiaPerforating ulcer
Hand sewnSingle layerComplicated
technicallyLots of potential
complications
Duodenal and jejunal techniquesEnterotomy and
resection-anastomosis
Appositional bestMaintains luminal
diameterLess fibrosis
Duodenal and jejunal techniquesSimple interrupted vs
simple continuousStaples vs suturesCompendium 2000
Simple continuous better apposition
FasterStaples – TA 35 (0.51
diameter close to 4.8mm x 3.4mm)Place 3 stay sutures
and staples in between
Duodenal and jejunal techniquesWhat do I do?
Ligaclips for vascular ligation
Maintain as much mesoduodenum or mesojejunum as possible
Suture terminal vessels
Duodenal and jejunal techniquesWhat do I do?
SI with 3-0 or 4-0 PDS
Take healthy bites 3-mm spacingDon’t worry about
mucosal eversion unless severe
Always leak test
Duodenal and jejunal techniquesEnterotomy
Pack off to minimize contamination
Surface to receive what is being removed
Have everything readyNeedle driversSutureThumb forcepsDoyens or assistant
No manipulation of vasculature
Duodenal and jejunal techniquesEnterotomy
Longitudinal incision to transverse closureIncreases luminal
diameterOnly used if small
incision (i.e. biopsy)Generally not
applicable at site of foreign body excision.
Good for closure of site to cut string
BE GENTLE especially with small thread foreign bodies
Typically hung in pylorus = gastrotomy
Typically require multiple enterotomiesReleasing and removingMinimize
Critically evaluate viability Mesenteric borderDuodenum adjacent to
ligamentConsider re-enforcements
Linear foreign bodies
Ileocolic techniques
IndicationsIntussusceptio
nNeoplasiaForeign body
Ileocolic techniquesSpecial considerations
Contamination issuesGram neg. and anerobes
Vasculature dissection more tedious
Separation of layersLuminal disparity
Oblique transectionVariable tissue spacingSpatulationEnd-to-side
Ileocolic techniquesSpecial considerations
Contamination issuesGram neg. and anerobes
Vasculature dissection more tedious
Separation of layersLuminal disparity
Oblique transectionVariable tissue spacingSpatulationEnd-to-side
Ileocolic techniquesSpecial considerations
Contamination issuesGram neg. and anerobes
Vasculature dissection more tedious
Separation of layersLuminal disparity
Oblique transectionVariable tissue spacingSpatulationEnd-to-side
TyphlectomyIndications
NeoplasiaCecal inversion
TechniqueIleocecal and
accessory cecocolic folds transected
TA stapler very handy
Simple interrupted
TyphlectomyIndications
NeoplasiaCecal inversion
TechniqueIleocecal and
accessory cecocolic folds transected
TA stapler very handy
Simple interrupted
TyphlectomyIndications
NeoplasiaCecal inversion
TechniqueIleocecal and
accessory cecocolic folds transected
TA stapler very handy
Simple interrupted
TyphlectomyIndications
NeoplasiaCecal inversion
TechniqueIleocecal and
accessory cecocolic folds transected
TA stapler very handy
Simple interrupted
Intra-op decisionsClosure re-
enforcementOmentum
Generally will attach without tacking.
Tacking may speed up the process
Serosal patchingTime consumingI perform if I am
worried
Intra-op decisions
Closure re-enforcementOmentum
Benefits Increased blood flow Rapid fibrin seal
Generally will attach without tacking.
Tacking may speed up the process
Serosal patchingTime consumingI perform if worried
Intra-op decisionsNutritional support
Jejunostomy tube
Explore again to make sure
Full thickness BIOPSYStomachDuodenum and
jejunum4-mm skin punch
biopsy(+/-) IleumDon’t biopsy colon
unless essential
What to do if negative explore
Intra-op decisionsLavage
Warm saline in water bath or microwave
200-300 ml/kgI use:
Small dogs and cats – 1-2 liters
Medium dogs – 2-3 liters
Large dogs – 4-6 liters
Keep flushing until clear
Remove blood clots