4. Intestinal Surgery Flashcards
1
Q
Beofr performing surgery on the small intestine what do we need to correct from V_ D+ and losses from the intestine?
A
Fluid losses! So institute fluid therapy
2
Q
Fluid therapy is used in combo with crystalloids and colloids depending on the patient and also to monitor electrolytes, It’s used for the treatment of _______
A
hypovolemia
3
Q
Surgery in the small intestine without spillage wuld be considered a _________(describe the contamination) versus surgery in the large intestine?
A
- Small intestine- clean contaminated
- Large intestine- contaminated
4
Q
What are the 4 main standards of viability to assess the small intestine integrity?
A
- Pink, moist glistening color
- Pulsation of mesenteric vessels
- Bleeding from cut surface
- Peristalsis- pinch test
5
Q
Seeing peristalsis is a good indicator of what?
A
Health
6
Q
For suturing principles of the small intestine, they must penentrate what layer
A
submucosa (holding layer)
7
Q
What type of pattern is recommended for small intestine surgery and are the types?
A
Appositional pattern recommended for primary healing
- Simple interrupted
- Simple continuous
8
Q
What is the name of another pattern we can use in regards to the small intestine to help with EVERTED MUCOSA?
A
Modified GAMBEE
9
Q
Can we use braided suture in the small intestine?
A
No! braided suture allows the bacteria to wick into layers
10
Q
Is the appositional pattern for SI sx a full thickness or partial thickness for simple interrupted?
A
Full thickness! Goes into the lumen
11
Q
Id the modifed gambee an appositional pattern? Does it enter the SI lumen?
A
It’s still an appositional pattern going through all the layers it just doesnt enter the lumen!
12
Q
What are the names of atraumatic forceps often used with SI sx? Where do we grasp tissue?
A
Debakey forceps; grasp tissue just at the cut edge minimally to reduce trauma
13
Q
What is the difference between intestinal biopsies and endoscopies?
A
Endoscopies can only get the mucosal layer! Intestinal biopsy is full thickness and takes 3-4 mm wide
14
Q
With longitudinal intestinal biopsies, a small wedge is taken on the along the length of the intestine on the _______ border
A
antimesenteric
15
Q
What is the size limiting consideration for a transverse wedge biopsy?
A
Wedge should not be over 20-25% of the circumference (otherwise you did a resection)
16
Q
When a transverse wedge biopsy is taken it’s a ______ thickness wedge, __-__mm wide taken ______ to the long axis of the intestine?
A
When a transverse wedge biopsy is taken it’s a FULL thickness wedge, 3-4 mm wide taken Perpendicular to the long axis of the intestine?
17
Q
Minimally invasive biopsies do alter some of the tissue but it is standard technique _______ assisted and uses a cutting/coagulation unit known as the _____ scalpel
A
Minimally invasive biopsies do alter some of the tissue but it is standard technique LAPAROSCOPIC assisted and uses a cutting/coagulation unit known as the HARMONIC scalpel
18
Q
For a small intestine obstruction the distension of the bowel occurs ______(___)
A
proximal (oral)
19
Q
With a proximal Intestinal obstruction it often involves the _____ or _____ and severe signs happen ______. Common signs are (4)?
A
With a proximal Intestinal obstruction it often involves the DUODENUM or PROXIMAL JEJUNUM and severe signs happen ACUTELY. Common signs are (4)?
- PERSISTENT V+
- GASTRIC SECRETIONS
- ELECTROLYTE IMBALANCES
- DEHYDRATION
20
Q
Compare and contrast the signs with a proximal intestinal obstruction to a distal intestinal obstruction in terms of severity?
A
Proximal IO: SEVERE and ACUTE
Distal IO: Vague, intermittent V+ and anorexia, lethargy, several days or weeks owners don’t notices these as much
21
Q
Plicated intestinal loops are pretty indicative of this?
A
linear FB
22
Q
What is the best imaging modality to reveal linear FB in the SI?
A
Ultrasound!
23
Q
We often use barium when suspecting a FB, when we we not use barium?
A
WHen there is evidence of a perforation, highly irritating the tissue and peritoneum
24
Q
What age brack and species often get linear FB?
A
Young animals and more cats than dogs
25
When do we start seeing CS for linear FB and where do we often find them on the cat?
CS occur when the FB becomes FIXED at some point CRANIALLY typically round the TONGUE or at pylourus (tongue more common in cats)
26
When you palpate a linear fb what do you often feel? Where should you check for them in terms of location?
Palpable bunching of intestines in central abdomen, check under the TONGUE
27
How do we free the linear FB from SI?
Free FB cranially by removing from the base of the tongue or performing gastrotomy
28
What must you examine when removing FB due to this comlication? What is it caused by?
Examine the MESENTERIC border for perforations it it the most common site for perforations
* Caused by peristalsis to the linear FB, pushing it like a saw over the mesenteric border
29
Should we pull the linear fb out as soon as we cut into the SI and see a portion?
NAHHH
Dont want to make perforations yourself so make multiple incisions and remove piece by piece
30
What are 2 major complications caused by linear FB besides perforation near the mesenteric border from peristalsis acting like a saw? List 2
1. Impaired function secondary to inflammatory changes
2. Short bowel syndrome with extensive resections causing watery D+ and weight loss (PSSSST you cn remove 80-85% of the SI)
31
How do we handle FB in terms of sx management?
* Always do a complete abdominal exploratory to make sure no other injuries
* Removal of the FB through a single enterotomy(ideal) ABORAL (DISTAL) to the FB to keep as much healthy tissue as possible
* If the tissue is non viable-resction and anasthemosis
32
In terms of location removing an FB _____ is the best to maintain tissue viability
aboral
33
What is the most important factor when considering fixing an intussusception?
There is always an underlying cause and you need to figure out what it is before sx treating because it will just reoccur!!
34
What are 2 common causes of intussusception that increase motility of the GIT
1. Parasitism
2. Parvovirus
35
Describe the imaging modality that gives way to a characteristic appearnace with Intussuception?
Ultrasoud!! Looks like a target lesion on transverse plane
36
What is the common signalment with intussuception?
Young puppies! (parasites or parvo)
37
Are acute or chronic signs more common with intussuception? What causes the chronic caused by?
Acute most common, chronic is caused by waxing and waning signs because it slides in and out
38
Intussuception feels like a _____ with abdominl palpation?
mass
39
What some different ways to surgically manage intussuception?
1. Exploratory celiotomy
2. Manual reduction as long as it easily pulls apart
3. Resection and ansthemosis if the tissue is non viable or reduction was unsucessful
4. Full thickness surgical Biopsy indicated if unodentifying underlying cause
40
Whats the main problem with manual reduction of intussuception?
Can occur again; tearing of the serosa which you won't have to resect unless deeper layers are affected
41
Recurrence of intussusception following surgical correction is not uncommon in dogs, and typically, the second intussusception develops at an anatomical location _____ from that of the initial intussusception." What is another procedure we can try to surgically manage to prvent recurrance and what does it do??
different; ENTEROPLICATION
Thus, to prevent recurrence, after manual reduction and, if necessary, resection and anastomosis, a technique known as **enteroplication** _is employed in which adjoining segments of intestine are laid out side-by-side in an accordion-like pattern of gentle loops or folds. Adjacent sections are then "sutured to each other with absorbable or non-absorbable sutures placed midway between the mesenteric or anti-mesenteric borders," essentially creating permanent serosal adhesions._ "The sutures may be placed in a simple-interrupted or simple-continuous pattern and should penetrate the submucosal layer of the intestine."
Must plicate the entire small intestine and avoid tight turns
42
What are some complications of enteroplication, what are the recurrence rates/complication and is this procedure highly recommended?
Obstruction
Strangulation
Perforation
Low recurrence rates of the intussuception 5%
Complication rate of the enteroplication procedure is 19%
This procedudre is not reccomended bc the risk outweights the beenfits, try really focsuing on discovering and treating the underlying cause of the intussuception
43
Cecal inversion is often known as cecal ______ and what are the main clinical signs?
Intussusception
-Chronic D+ with hematochezia (passage of blood through anus)
44
What are some treatment options for cecal intussuception?
Attempt manual reduction
Expose through colotomy if irreducible
Typhlectomy
45
What is a typhlectomy?
Removal of the cecum
46
What is mesentaeric volvulus?
Rare often fatas condition where the intestines twist on the mesenteric axis
47
What breed is associated with mesentaeric volvulus
German shepherds :-(
48
If mesentaeric volvulus is focal it can be \_\_\_\_\_\_\_
treatable
49
When the intestines twist on the mesenteric access with mesentaeric volvulus what 2 things happen?
Strangulating mechanical obstruction
Ischemia of SI
50
mesentaeric volvulus often presents very similarly to ____ with acute abdominal distension and pain, V+ and shock present often
GDV
51
What is the key difference betweeen mesentaeric volvulusand GDV in terms of treatment
mesentaeric volvulus is nonrespnsive to orogastric intubation they are still going to be painful it provided no relief!
52
What do you do as soon as you confirm mesenteric volvulus?
Rapid fluid resuscitation and immedite abdominal exploratory to see whether or not you need to retotate or if't not viable resection and ansthemosis
53
What is the best case scenario in terms of mesentaeric volvulus for a better prognosis
segmental with out derotation
54
What are some things you can do to minimize contamination with intestinal surgery?
* -pack off affected area
* -separate instruments to be used for intestinal procedures from the rest of the pack
* -Occlude intestne proximal and distal to control contents gushing out (if empty not mandatory to decrease trauma)
* -Decompress dilated bowel loops
* Gentle tissue handling
55
After occluding proximal and disital segments atraumatically to prevent spillage, what do we begin doing next at what location, also state what we want to prevent?
Begin anastomosis at the mesenteric border, minimize mucosal eversion
56
What patterns do we use with intestinal resection and anasthomosis and what do we end the prooedure with in terms of intestinal resection and anasthemosis
Interrupted or continuous suture pattern, close rent in mesentery, wrap anastomosis with omentum
57
When we cut the mesentery where do we cut it?
Cut mesentery close to vessels of the segment being removed
58
What are the pros and cons with scissors and scalpel use with intestinal surgery?
Scissors-more control, more traumatic
Scalpel- less control, less traumatic
59
Angling the cut for the small intestine does what?
enlarges the lumen size initially to account for the 10-20% narrowing which typically occurs during healing
60
Mucosal eversion increases the risk of _______ and ______ formation
infection; adhesion
61
If you cut the mucosal layer of the intestine you will see ______ so implement this suturing technique\_\_\_\_\_\_\_\_\_?
bleeding; modifed gambee to close the intestine
62
For resection and anstomosis procedures involving the intestine where do you begin your anastomosis?
mesenteric border
63
When begining your anastomosis at the ______ \_\_\_\_\_ what is commonly seen at this site in terms of complications and why? (2)
mesenteric border; leackage is the most common at this site because theres no serosa to seal and fat in the mesentery impairs visuualization
64
WHat should you always do after performing an anastomosis?
Leak test! occlude proximally and distally and inject saline until evenly distended and gently compress and look for leaks
65
When using skin staples for anstomosis make sure the staples do this?
close tightly at the tips
66
Proximal intestines will stay dilated for a while, what are some things you can do to help?
* Cut smaller segments at an larger angle,
* space sutures closer on the smaller segment,
* placing mesenteric and antimesenteric sutures stretches smaller segment,
* fishmouth or cheattle incision
67
Make sure you close the _____ in the mesentary to prevent an _______ \_\_\_\_\_\_\_
rent; entrapping strangulation
68
At the end of your anastomosis make sure you _____ and do not use previous instruments as they are contaminated
lavage
69
The _________ is very imp in reducuing the risk of wound healing problems after intestinal surgery, it contains a rich _____ and ______ supply to aid in healing
omentum; vascular; lymphatic
70
When omentum is necrotic or not available to use you may use a ______ patch to reinforce questionable tissue suture lines. Compare it to omentum?
Serosal; it induces a permanent adhesion much stronger than omentum
71
We use serosal patches for reinforcement of suture lines in questionable tissue such as _____ \_\_\_\_\_\_ and in _____ and \_\_\_\_\_\_\_procedures
urinary bladder; enterotomy; colotomy;
72
Compare and contrast the bacterial numbers in small versus large intestine?
the large intestine high
73
Describe the healing of the large intestine?
Initially, strength of the wound is weak there is a 3-4 day lag period. Collagenolysis (low collagen strength). Wound stregnth 75% of normal at 4 months- slower than SI.
74
The blood supply of the large intestine is different from the SI mesenteric blood supply how? What does it maintain?
Segmental-vasarecta, maintains tissue perfusion
75
What are the 3 main indications for a colonotomy?
- FB removal
- Impacted feces
- Biopsy
76
Describe the closure for a colonotomy?
Longitudinal simple interruped appositional
77
If the mango pit has entered the colon, should we jump right into a colonotomy?
Avoid having to mke and incision in the colon bc once a FB has gotten into the colon ideally they should be able to pass through.
Once you have opened them up and seen the FB is now in the colon, instrad of making an incision into the colon try to milk the FB through more caudally and have an assistant retrieve it rectally
if it's stuck! You will need to perform a colonotomy
78
What does a colopexy do? Where do we perform this?
Creates a permanent adhesion between the colon and abdominal wall, on the left side due to the location of the colon!!
79
What are the indications for colopexy?
* -Recurrent rectal prolapse
* -Recurrent perineal hernia where the colon keeps pushing on the perineal wall
80
On what side of the body do we pexy the colon to in a colopexy?
left
81
What are the 2 types of colopexys and details with each?
* Incisional- don't cut into the lumen or into the mucosam where there is a dinstinct separation of layers visable
* Nonincisional-pass needs through to submucosa layers to make sure the holding layer is implemented and no incision is required
82
WHAT ARE THE 4 MAIN INDICATIONS FOR COLONIC RESECTION AND ANASTHEMOSIS?
* Megacolon
* Perforation
* Neoplasia
* Irreducible/necrotic intussuception
83
What are the different techniques used for colonic resection and anasthemosis?
* -Partial colectomy
* -Subtotal colectomy where you remove as much of the colon as possible especially with megacolon, with or without preservation of the ileocecal valve
84
Megacolon happens more often in _____ and what are the 4 causes (also state the most common of the 4)
CATS\>\>dogs
* Idiopathic (MOST COMMON)
* Congenital versus acquired
* Mechanical functional colonc obstruction
* Neurologic
85
What is happening with distension and water with megacolon?
Water is continuously being pulled out of the feces because thats the role of the colon and the feces cants move through and become hard and impacted to to lack of fluids to helps move smoothly
86
What happens with the feces in megacolon
Concretions form and they are painful and often too large to pass
87
What dpes prolonged distension cause in megacolon (2)?
Smooth muscle damage, nerve damage
88
Congenital megacolon is due to this reason(state the reason) and happens in rare instances in \_\_\_\_.
rare in cats
caused by aganglionic DISTAL colonic segement and absence of inhibitory neurons causing a functional obstruction
89
What are some neurologic consditions that can cause megacolon?
* -Lumbosacral disease
* KEY GASKELL (feline progressive dysautonomia
* -Sacral SPinal cord deformity in manx cats
90
Manx cats are predisposed to ______ due to this
megacolon, due to this neurologic condition known as sacral spinal cord deformity
91
What is key gaskell?
its a neurlogic condition that can cuase megacolon, known as feline progressive dysautonomia
92
Getting hit by a car may predispose a dog to getting \_\_\_\_\_\_\_, due t what reason? What can we do to fix it with a good prognosis if caught early?
megacolon due to callus formation from the healing of the pelvic fracture and SI luxation, Dependent on the degree of distension, doing a pelvic osteotomy yileds a good prognosis if caught early within less than 6 months
93
What are some delayed complications realted to obstructuve/entrapment surgical causes of megacolon, when wil CS occur?
Adhesion formation from OVH, CS may occur weeks to years post op and might even be an incidental finding if no problem was caused on exploratory
94
What are the 2 treatments for megacolon from obstructive issues or entrapment
* Surgical dissection and removal
* Potential for resection and aanastomosis
95
Primary/Idiopathic is the most common cause of _____ in cats
megaclon; cats
96
Before diagnosis megacolon as primary/idiopathic you need todo this?
Rule out 2\* causes!!! like pelvic trauma (include pevis on rads!!), nerologic disease, perineal henria
97
What is an alleged etiology of primary or idiopathic megacolon? What is a possible medicinal tx?
Dysfunction of colonic smooth muscle due to a decrease in contractility versus colonic dilatation (maybe use cisapride to encourage smooth muscle motlity)
98
Can we manage primary/idiopathic megacolon with medical and sx management? Describe some details of reoccurance in terms of sx and what we need to keep in mind?
YESS Medical versus Sx management
-Sx, cant remove all the colon and can still have REOCCURANCE espeically with a colocolonic anasthomosis. needs to still leave some colon bc of ileal rectal artery, need to maintain blood supply to the rectum
99
We first try ______ in terms of treatment of megacolon
Medical management
100
What are some different ways we can aid in medical management of megacolon?
* Diets
* Low residue Diets
* Hydration
* Enemas
* deobstipation under general anesthesia
* Prokinetic drugs
* Cisapride
* Stool softeners
* Lactulose
101
Does reoccurance happenw ith surgical management of megacolon?
yes its possible!
102
If medical management is unsuccessful we next try ____ for megacolon
surgery
103
In terms of colectomy's with surgical management of megacolon what types can we do?
* Colocolonic ansthemosis (reoccurance high)
* Ileocolic anasthemosis
* Jejunocolic anasthomosis
104
If we attempt to preserve the ileocecal valce is there any clinical benefit? What can it cause?
NO CLINICAL BENEFIT
- The positive: bacterial overgrowth prevented (D+ will arise but will adapt)
- Negative: increases tension at anastomosis
105
Surgical management of megacolon is a ______ surgery and what to things do we not alow prior to sx?
contaminated;
* No enemas few days post op
* No stool softeners better to have firm feces that wont leak into abdomen and cause spillage
106
What are some CS we may see post operatively we need to warn owners about (3) after surgery for megacolon?
* Tenesmus up to 7 days after
* D+ and lose stool for weeks
* Increased frequency of defecation
May need to put them in a bathroom or somewhere with out carpet!
107
What are 2 major complications that occur from megacolon sx?
* Dehiscence
* Recurrance (if we leave park of the colon increases likelhood)
108
In terms of post op considerations for megacolon sx patients what should we consider 3?
* Taper fluid and electrolyte therapy as oral intake returns to normal
* Offer food and water **_THE DAY AFTER_** sx unless contraind. More protein intake =faster healing
* Pain management
109
When do most complications occur with GI surgery patients?
Not on day 1 after but 3 to 5 days due to the lag phase of healing
110
What does the CBC indicate that could cause complications after GI sx?
-Neutrophils and bands that indicate increased dehiscence
111
What would an abdomincentesis indicate that would be a poor prognostic indicatory after GI sx?
inflammatory cells and bacteria
112
There's always a potential for post operative _____ with intestinal sx. what do I do if that happens?
ileus; immediate post time frame give prokinetics and do a NG tube for feeding
113
What are some complications following intestinal sx?
* Ileus always a potential
* adhesion
* obstruction
* INTUSSUCEPTION
* ENTRAPMENT
* STENOSIS
* Dehiscence
* Peritonitis
* Short bowel syndrome
114
What are some risk factors for DEHISCENT after intestinal surgery? (4)
* FB and trauma
* **Preoperative** _ALBUMIN \<2.5 g/dl_
* **Post op** rise in band neutrophils
* **Pre-op** _peritonitis_
115
With intestinal surgery, \_\_\_\_\_/\_\_\_\_\_ increases mortality rates. WHat % of dehiscence indicates a high mortality? If theres none from the hospital what does this indicate
* leakage/dehiscence
* Dehiscence rate of 7-15% = mortality 74-85%
* If no dehiscence and discharge from the hospital = good overall prognosis
