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6th MELEAH Surgery test 2 (gonna make it my bitch) > 4. Intestinal Surgery > Flashcards

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

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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

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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
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4
Q

What are the 4 main standards of viability to assess the small intestine integrity?

A
  1. Pink, moist glistening color
  2. Pulsation of mesenteric vessels
  3. Bleeding from cut surface
  4. Peristalsis- pinch test
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5
Q

Seeing peristalsis is a good indicator of what?

A

Health

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6
Q

For suturing principles of the small intestine, they must penentrate what layer

A

submucosa (holding layer)

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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
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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

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9
Q

Can we use braided suture in the small intestine?

A

No! braided suture allows the bacteria to wick into layers

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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

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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!

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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

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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

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14
Q

With longitudinal intestinal biopsies, a small wedge is taken on the along the length of the intestine on the _______ border

A

antimesenteric

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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)

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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?

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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

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18
Q

For a small intestine obstruction the distension of the bowel occurs ______(___)

A

proximal (oral)

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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
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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

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21
Q

Plicated intestinal loops are pretty indicative of this?

A

linear FB

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22
Q

What is the best imaging modality to reveal linear FB in the SI?

A

Ultrasound!

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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

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24
Q

What age brack and species often get linear FB?

A

Young animals and more cats than dogs

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25
Q

When do we start seeing CS for linear FB and where do we often find them on the cat?

A

CS occur when the FB becomes FIXED at some point CRANIALLY typically round the TONGUE or at pylourus (tongue more common in cats)

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26
Q

When you palpate a linear fb what do you often feel? Where should you check for them in terms of location?

A

Palpable bunching of intestines in central abdomen, check under the TONGUE

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27
Q

How do we free the linear FB from SI?

A

Free FB cranially by removing from the base of the tongue or performing gastrotomy

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28
Q

What must you examine when removing FB due to this comlication? What is it caused by?

A

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
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29
Q

Should we pull the linear fb out as soon as we cut into the SI and see a portion?

A

NAHHH

Dont want to make perforations yourself so make multiple incisions and remove piece by piece

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30
Q

What are 2 major complications caused by linear FB besides perforation near the mesenteric border from peristalsis acting like a saw? List 2

A
  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)
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31
Q

How do we handle FB in terms of sx management?

A
  • 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
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32
Q

In terms of location removing an FB _____ is the best to maintain tissue viability

A

aboral

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33
Q

What is the most important factor when considering fixing an intussusception?

A

There is always an underlying cause and you need to figure out what it is before sx treating because it will just reoccur!!

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34
Q

What are 2 common causes of intussusception that increase motility of the GIT

A
  1. Parasitism
  2. Parvovirus
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35
Q

Describe the imaging modality that gives way to a characteristic appearnace with Intussuception?

A

Ultrasoud!! Looks like a target lesion on transverse plane

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36
Q

What is the common signalment with intussuception?

A

Young puppies! (parasites or parvo)

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37
Q

Are acute or chronic signs more common with intussuception? What causes the chronic caused by?

A

Acute most common, chronic is caused by waxing and waning signs because it slides in and out

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38
Q

Intussuception feels like a _____ with abdominl palpation?

A

mass

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39
Q

What some different ways to surgically manage intussuception?

A
  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
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40
Q

Whats the main problem with manual reduction of intussuception?

A

Can occur again; tearing of the serosa which you won’t have to resect unless deeper layers are affected

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41
Q

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??

A

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

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42
Q

What are some complications of enteroplication, what are the recurrence rates/complication and is this procedure highly recommended?

A

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

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43
Q

Cecal inversion is often known as cecal ______ and what are the main clinical signs?

A

Intussusception

-Chronic D+ with hematochezia (passage of blood through anus)

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44
Q

What are some treatment options for cecal intussuception?

A

Attempt manual reduction

Expose through colotomy if irreducible

Typhlectomy

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45
Q

What is a typhlectomy?

A

Removal of the cecum

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46
Q

What is mesentaeric volvulus?

A

Rare often fatas condition where the intestines twist on the mesenteric axis

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47
Q

What breed is associated with mesentaeric volvulus

A

German shepherds :-(

48
Q

If mesentaeric volvulus is focal it can be _______

A

treatable

49
Q

When the intestines twist on the mesenteric access with mesentaeric volvulus what 2 things happen?

A

Strangulating mechanical obstruction

Ischemia of SI

50
Q

mesentaeric volvulus often presents very similarly to ____ with acute abdominal distension and pain, V+ and shock present often

A

GDV

51
Q

What is the key difference betweeen mesentaeric volvulusand GDV in terms of treatment

A

mesentaeric volvulus is nonrespnsive to orogastric intubation they are still going to be painful it provided no relief!

52
Q

What do you do as soon as you confirm mesenteric volvulus?

A

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
Q

What is the best case scenario in terms of mesentaeric volvulus for a better prognosis

A

segmental with out derotation

54
Q

What are some things you can do to minimize contamination with intestinal surgery?

A
  • -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
Q

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?

A

Begin anastomosis at the mesenteric border, minimize mucosal eversion

56
Q

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

A

Interrupted or continuous suture pattern, close rent in mesentery, wrap anastomosis with omentum

57
Q

When we cut the mesentery where do we cut it?

A

Cut mesentery close to vessels of the segment being removed

58
Q

What are the pros and cons with scissors and scalpel use with intestinal surgery?

A

Scissors-more control, more traumatic

Scalpel- less control, less traumatic

59
Q

Angling the cut for the small intestine does what?

A

enlarges the lumen size initially to account for the 10-20% narrowing which typically occurs during healing

60
Q

Mucosal eversion increases the risk of _______ and ______ formation

A

infection; adhesion

61
Q

If you cut the mucosal layer of the intestine you will see ______ so implement this suturing technique_________?

A

bleeding; modifed gambee to close the intestine

62
Q

For resection and anstomosis procedures involving the intestine where do you begin your anastomosis?

A

mesenteric border

63
Q

When begining your anastomosis at the ______ _____ what is commonly seen at this site in terms of complications and why? (2)

A

mesenteric border; leackage is the most common at this site because theres no serosa to seal and fat in the mesentery impairs visuualization

64
Q

WHat should you always do after performing an anastomosis?

A

Leak test! occlude proximally and distally and inject saline until evenly distended and gently compress and look for leaks

65
Q

When using skin staples for anstomosis make sure the staples do this?

A

close tightly at the tips

66
Q

Proximal intestines will stay dilated for a while, what are some things you can do to help?

A
  • 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
Q

Make sure you close the _____ in the mesentary to prevent an _______ _______

A

rent; entrapping strangulation

68
Q

At the end of your anastomosis make sure you _____ and do not use previous instruments as they are contaminated

A

lavage

69
Q

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

A

omentum; vascular; lymphatic

70
Q

When omentum is necrotic or not available to use you may use a ______ patch to reinforce questionable tissue suture lines. Compare it to omentum?

A

Serosal; it induces a permanent adhesion much stronger than omentum

71
Q

We use serosal patches for reinforcement of suture lines in questionable tissue such as _____ ______ and in _____ and _______procedures

A

urinary bladder; enterotomy; colotomy;

72
Q

Compare and contrast the bacterial numbers in small versus large intestine?

A

the large intestine high

73
Q

Describe the healing of the large intestine?

A

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
Q

The blood supply of the large intestine is different from the SI mesenteric blood supply how? What does it maintain?

A

Segmental-vasarecta, maintains tissue perfusion

75
Q

What are the 3 main indications for a colonotomy?

A
  • FB removal
  • Impacted feces
  • Biopsy
76
Q

Describe the closure for a colonotomy?

A

Longitudinal simple interruped appositional

77
Q

If the mango pit has entered the colon, should we jump right into a colonotomy?

A

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
Q

What does a colopexy do? Where do we perform this?

A

Creates a permanent adhesion between the colon and abdominal wall, on the left side due to the location of the colon!!

79
Q

What are the indications for colopexy?

A
  • -Recurrent rectal prolapse
  • -Recurrent perineal hernia where the colon keeps pushing on the perineal wall
80
Q

On what side of the body do we pexy the colon to in a colopexy?

A

left

81
Q

What are the 2 types of colopexys and details with each?

A
  • 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
Q

WHAT ARE THE 4 MAIN INDICATIONS FOR COLONIC RESECTION AND ANASTHEMOSIS?

A
  • Megacolon
  • Perforation
  • Neoplasia
  • Irreducible/necrotic intussuception
83
Q

What are the different techniques used for colonic resection and anasthemosis?

A
  • -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
Q

Megacolon happens more often in _____ and what are the 4 causes (also state the most common of the 4)

A

CATS>>dogs

  • Idiopathic (MOST COMMON)
  • Congenital versus acquired
  • Mechanical functional colonc obstruction
  • Neurologic
85
Q

What is happening with distension and water with megacolon?

A

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
Q

What happens with the feces in megacolon

A

Concretions form and they are painful and often too large to pass

87
Q

What dpes prolonged distension cause in megacolon (2)?

A

Smooth muscle damage, nerve damage

88
Q

Congenital megacolon is due to this reason(state the reason) and happens in rare instances in ____.

A

rare in cats

caused by aganglionic DISTAL colonic segement and absence of inhibitory neurons causing a functional obstruction

89
Q

What are some neurologic consditions that can cause megacolon?

A
  • -Lumbosacral disease
  • KEY GASKELL (feline progressive dysautonomia
  • -Sacral SPinal cord deformity in manx cats
90
Q

Manx cats are predisposed to ______ due to this

A

megacolon, due to this neurologic condition known as sacral spinal cord deformity

91
Q

What is key gaskell?

A

its a neurlogic condition that can cuase megacolon, known as feline progressive dysautonomia

92
Q

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?

A

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
Q

What are some delayed complications realted to obstructuve/entrapment surgical causes of megacolon, when wil CS occur?

A

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
Q

What are the 2 treatments for megacolon from obstructive issues or entrapment

A
  • Surgical dissection and removal
  • Potential for resection and aanastomosis
95
Q

Primary/Idiopathic is the most common cause of _____ in cats

A

megaclon; cats

96
Q

Before diagnosis megacolon as primary/idiopathic you need todo this?

A

Rule out 2* causes!!! like pelvic trauma (include pevis on rads!!), nerologic disease, perineal henria

97
Q

What is an alleged etiology of primary or idiopathic megacolon? What is a possible medicinal tx?

A

Dysfunction of colonic smooth muscle due to a decrease in contractility versus colonic dilatation (maybe use cisapride to encourage smooth muscle motlity)

98
Q

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?

A

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
Q

We first try ______ in terms of treatment of megacolon

A

Medical management

100
Q

What are some different ways we can aid in medical management of megacolon?

A
  • Diets
    • Low residue Diets
  • Hydration
  • Enemas
    • deobstipation under general anesthesia
  • Prokinetic drugs
    • Cisapride
  • Stool softeners
    • Lactulose
101
Q

Does reoccurance happenw ith surgical management of megacolon?

A

yes its possible!

102
Q

If medical management is unsuccessful we next try ____ for megacolon

A

surgery

103
Q

In terms of colectomy’s with surgical management of megacolon what types can we do?

A
  • Colocolonic ansthemosis (reoccurance high)
  • Ileocolic anasthemosis
  • Jejunocolic anasthomosis
104
Q

If we attempt to preserve the ileocecal valce is there any clinical benefit? What can it cause?

A

NO CLINICAL BENEFIT

  • The positive: bacterial overgrowth prevented (D+ will arise but will adapt)
  • Negative: increases tension at anastomosis
105
Q

Surgical management of megacolon is a ______ surgery and what to things do we not alow prior to sx?

A

contaminated;

  • No enemas few days post op
  • No stool softeners better to have firm feces that wont leak into abdomen and cause spillage
106
Q

What are some CS we may see post operatively we need to warn owners about (3) after surgery for megacolon?

A
  • 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
Q

What are 2 major complications that occur from megacolon sx?

A
  • Dehiscence
  • Recurrance (if we leave park of the colon increases likelhood)
108
Q

In terms of post op considerations for megacolon sx patients what should we consider 3?

A
  • 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
Q

When do most complications occur with GI surgery patients?

A

Not on day 1 after but 3 to 5 days due to the lag phase of healing

110
Q

What does the CBC indicate that could cause complications after GI sx?

A

-Neutrophils and bands that indicate increased dehiscence

111
Q

What would an abdomincentesis indicate that would be a poor prognostic indicatory after GI sx?

A

inflammatory cells and bacteria

112
Q

There’s always a potential for post operative _____ with intestinal sx. what do I do if that happens?

A

ileus; immediate post time frame give prokinetics and do a NG tube for feeding

113
Q

What are some complications following intestinal sx?

A
  • Ileus always a potential
  • adhesion
  • obstruction
    • INTUSSUCEPTION
    • ENTRAPMENT
    • STENOSIS
  • Dehiscence
  • Peritonitis
  • Short bowel syndrome
114
Q

What are some risk factors for DEHISCENT after intestinal surgery? (4)

A
  • FB and trauma
  • Preoperative ALBUMIN <2.5 g/dl
  • Post op rise in band neutrophils
  • Pre-op peritonitis
115
Q

With intestinal surgery, _____/_____ increases mortality rates. WHat % of dehiscence indicates a high mortality? If theres none from the hospital what does this indicate

A
  • leakage/dehiscence
  • Dehiscence rate of 7-15% = mortality 74-85%
  • If no dehiscence and discharge from the hospital = good overall prognosis

6th MELEAH Surgery test 2 (gonna make it my bitch) (8 decks)

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