Abdominal Surgery Flashcards
What are the surgical approaches to abdominal surgery?
Ventral midline, paracostal, flank, laparoscopic (needs extra advanced training)
What kind of biopsies are done on LN? What about Mesenteric LN?
Done in surgery (easiest) or FNA through skin. However, Mesenteric LN’s are really sensitive and you might destroy those if you don’t do it with surgery with a wedge biopsy.
What’s special about intestinal biopsies?
Treat it like a clean contaminated wound. If you know you’re doing a clean surgery, then do this biopsy last and swap the gloves and instruments when you’re closing up so you don’t get fecal material in the SQ or other spaces. You need lap sponges, to pack the area and be super gentle with the samples (crush injuries from forceps very easy)
How do you prevent intestinal contents from flying out after a biopsy?
You get an assistant to hold it off
How do you do liver biopsies and what are the benefits of each method?
Guillotine biopsy: where you tie a monofilament suture around an edge of the lobe and cut it off, punch biopsy: good for lesions that are not near edge of lobe, Laparoscopy: is an easier procedure to recover from cause you don’t open up the entire chest, just send in this arm with a camera and forceps and take a snip of the liver.
Which of the 3 liver biopsies techniques is easiest to recover from?
Probably the laparoscopy method, unless we have bad coagulopathies, the dog can go home the same day. The biopsy method you could put gel foam in the biopsy spot to seal it up.
Give examples of organs (x7) that you need to think twice about biopsies
Kidney (higher risk, don’t hit the medulla cause it bleeds a lot), Pancreas (only if there are gross lesions or specific pancreatic conerns, we’re worried about pancreatitis post-op, very temperamental organ, only do if you think you have EPI), Bladder (not a routine exploratory laparotomy), Spleen (not on route ex lap), Adrenal glands (just no), body wall (sometimes), Omentum (guillotine like biopsy)
What are some causes of inflammatory peritoneum (peritonitis)?
Primary causes: FIP in cats; secondary causes: sequelae of other things like –> Aseptic = foreign body, ruptured neoplasm, pancreatic enzymes, bile, urine, stomach or proximal duodenal contents, diffuse neoplasia (carcinomatosis/sarcomatosis/mesotheliomas) or Septic = bowel perforation or dehiscence, penetrating wounds, surgical contamination, ruptured pyometra or prostatic abscess, urine or bile with bacterial load.
What are some clinical signs related to peritonitis? (they’re kinda non-specific)
Depression, abdominal pain, nausea, vomiting, anorexia, diarrhea
What are some more specific clinical signs of peritonitis?
Fever and leukocytosis but are not consistent
What might you see on BCHEM and CBC for peritonitis?
Leukocytosis with left shift or neutropenia; Elevated BUN, creatinine, potassium possibly due to uroperitoneum; if it is bile peritonitis you might see elevated bilirubin, alk phosph, alanine transaminase; with septic peritonitis you may see hypoglycemia, hyperlactatemia
What might abdominal radiographs who in an animal with peritonitis?
Free air present in abdomen (but if you’ve opened up the abdomen, it could persist in there for 3 weeks postop), lack of serosal detail suggestive of effusion.
What’s the gold standard for peritonitis diagnosis?
Obtain peritoneal fluid (US guided), conduct cytology/clin path on it to determine degenerative neutrophils, bacteria = septic, measure the fluid and compare markers of bilirubin, creatinine, glucose, lactate to the blood. Bile crystals = bile peritonitis
QUICK TRIAGE, THERE’S SHOCK FROM PERITONITIS, what do we do?!
Aggressive patient stabilization like: IV fluids (crystalloid and depends on bloodwork: LRS, plasmalyte are well balanced, NaCl if they’re hypochloremic, hypokalemic so add in K, if they’re hypocalcemic, don’t bolus calcium but have them on plasmalyte and add calcium), pain meds and anti-inflammatories (injectable opioids, ketamine, lidocaine), Antibiotics (i know you want a sample, but prioritize saving hte life- broad spectrums like enrofloxacin, ampicillin, metronidazole, piperacillin tazobactam, cefoxitin), vasopressors/ionotropic meds to help with heart function and BP, blood products if indicated
What are the surgical steps to peritonitis?
Removal of inciting cause (resect bowel, remove FB, debride abscess, OVH for ruptured pyometra, etc.), lavage abdominal wall (just until it’s not a gross colour and more serosanguinous- fluids can make them realy hypotensive and cold so use it warmed), drainage of peritoneal cavity (closed suction only, open management no longer suggested –> careful of hypoproteinemia, hypoalbuminemia and electrolyte disturbances as well as infection and pain)
What’s the general prognosis for peritonitis?
Variable but at best it is guarded (50/50), the earlier to I ntervene the better
What can penetrating traumas cause internally?
Direct perforation of the bowel
What can blunt trauma cause in the abdomen?
Immediate tears or vascular compromise to organs
What’s a good and bad predictor of abdominal trauma cases, diagnostically?
Clinical and lab findings are not good predictors, abdominal radiographs or peritoneal lavage (diagnostic) are good predictors
What makes a penetrating wound in the abdomen a bad prognosis?
Generally, a perforated bowel, major abdominal hemorrhage and perforation of organs worsens the prognosis greatly, it depends on the extend of damage as well
T/F: The stomach is a complicated organ to conduct surgery on because of its overabundance of vasculature, it has a lot of complications.
False: the stomach has an overabundance of blood supply which is why it can heal so well, it tends to be a straightforwards and low complication rate surgery.
Which organs attached to the stomach make it problematic for the stomach?
Pancreas, duodenum, gall bladder
Why does the stomach need such a large blood supply?
It helps with making the mucosa in the stomach so HCl doesn’t melt right through it.
What are reasons we would have to conduct surgery on the stomach?
Biopsy, foreign body, GDV/prophylactic gastropexy, GI tube placement, neoplasia, outflow obstruction, hiatal hernia, gastroesophageal intussusception
IF we had an outflow obstruction of the stomach, what would bloodwork indicate?
Hypochloremia, metabolic alkalosis (losing all your chloride and acid), as the animal gets more sick, this metabolic alkalosis gets less consistent
Why is a gastrotomy safer than an enterotomy?
Gastrotomy is safer because of the size of the stomach > intestine, blood supply is more, easy closure, bacterial types are less troublesome and there are less complications
What are the two most common indications for a gastrotomy?
Biopsy (IBD or diffuse neoplastic process like lymphoma), foreign body removal (most common)
Where should you incise for a gastrotomy?
incise between the greater and lesser curvature in a relatively avascular location
What are some mandatory things you need for a gastrotomy?
You need an assistant, suction since there’s a lot of fluid, PDS (single continuous or inverted pattern) and evaluate the entire GI tract, don’t get tunnel vision
What is gastric dilatation and volvulus?
Accumulation of air in the stomach, gastric malpositioning to the point that the CVC is obstructed so blood from legs can’t gt to heart and diaphragm obstructing breathing. Volvulus makes it look worse too. Stomach rotates clockwise 180-270 degrees, you get gastric ischemia, necrosis and perforation. Systemically there is obstructive and hypovolemic shock due to everything and splenic effects (bleeding from gastric vessels, congestion, torsion of the spleen too)
What are some risk factors of GDV?
Large, giant deep chested dogs, stress, feeding (large amounts or eating too fast or just one type of dry food), increasing age, male, hereditary, previous splenectomy (less anchoring, overall less room), post-prandial exercise
How do you diagnose a GDV?
Signalement and history (retching - nonproductive, distended abdomen, restlessness, ptyalism, tachypnea, dyspnea, shock symptoms)
What might a dog with GDV indicate on bloodwork?
lactate levels may be increased due to ischemia, check there is no coagulopathies cause you’re going to surgery and make sure liver and kidneys are ok.
What pain management are we using for GDV?
fentanyl, hydromorphone helps with tachycardia and arrhythmias, Since the pancreas is attached to the stomach, it tells the rest of the body it is mad so VPCs (spleen also contributes)
What do we give to the dog to control the VPC’s or Vtachs associated with arrhythmias from GDV?
Lidocaine
How do we immediately stabiize GDVs?
Trocharize it or add a gastric tube both under anesthesia or sedation to decompress. Provide fluids (at least 2 and bolus on front legs and crystalloids), prepare it for emergency surgery
Once GDV dog is stable, what do we do and why?
Abdominal radiographs in RIGHT LATERAL (will see gas distended stomach with compartmentalization, if you think there’s a FB do a left lateral first.
Describe radiograph of a GDV dog in right lateral
you’ll see a fluid filled stomach, super distended, you’ll see a curling stone figure, popeyes arm when it’s really fluid/gas filled. You’l see a dilated esophagus cause of aerophagia, megaesophagus, look for vena cava cause it’ll be so thin
What’s the next few after right lateral to determine GDV?
DV
Briefly describe the surgery for a GDV from positioning of the animal to just before closing
Dorsal recumbency, long ventral midline incision (xiphoid to pubis), don’t perforate the stomach cause it’s super distended, detrosion (grab duodenum and push stomach ventrally and to left - might need orogastric tube), assess gastric viability, check other organs like spleen and stomach wall, look for FB and concurrent masses/nodules
Why might you do a splenectomy during a GDV surgery?
The spleen is torsed around the vascular pedicle, lack of arterial pulsation in mesentery of spleen, if it was congested initially and after you detorse the GDV and it’s not getting pinker by end of surgery… then cut it out
During the gastrectomy, what indicates a poorer prognosis.. When what is involved?
Poorer prognosis if cardia of stomach is involved and if the stomach is black and white. Sometimes you have to resect the stomach, but itll likely torse towards cardia.. It’s a tough call
What are indications to due gastropexy on left or right?
Left: hiatal hernia and gastroesophageal intusussception; right: GDV or prophylactic pexy (if you cut a GDV, you have to pexy)
What’s an incisional gastropexy?
Slit through transversus at pyloric antrum, not full thickness (not through mucosa), attach it to just behind last rib
What must you monitor on ECG after post-op?
VPC/Vtach for atleast 24 hours to find arrhythmias
T/F: mortality rate of GDV’s afer surgery is 10%
TRUE
What’s the difference between acquired and congenital hypertrophic pylorogastropathy?
Congenital: muscular layer, pyloric stenosis and normally in young (<1yo) brachys. Acquired: mucosal or mucosal and muscular layers, small breed dogs.
What does a hypertrophic pylorogastropathy look like coming in to the clinic?
chronic intermittent vomiting with increasing frequency (Ddx is chronic foreign body)
What’s a good way to diagnose hypertrophic pylorogastropathy?
U/S and CT or barium radiographs but difficult
What’s a gastroesophageal intussusception and how common is it?
Stomach slides in and out of chest through the esophagus. Need to close the hiatus and pexy the stomach
What’s type 1-4 hiatal hernia?
Type 1: sliding hiatal hernia, type 2: paraesophageal hiatal hernia (part of fundus slides into thorax along with esophagus), Type 3: combo of 1 and 2, Type 4: herniation of abdominal contents through esophageal hiatus.
What’s the most common gastric neoplasia in dogs, cats?
Dogs: gastric adenocarcinoma; cats: lymphosarcoma
What are two other gastric neoplasias?
Leiomyosarcoma, fibrosarcoma
As you move towards the ____ the worst the prognosis of gastric neoplasia placement
Pylorus
Which arteries supply part of the duodenum and originates from a branch of the celiac artery?
Hepatic and cranial pancreatic duodenal artery
What’s one way to tell where the ileum is on the small intestine?
It’s the only part that has a visible blood supply (antimesenteric vessels)
What exits out the major duodenal papilla?
common bile duct
What might you see on bloodwork of small intestinal diseases?
Electrolyte imbalances due to dehydration or vomiting/diarrhea (hypochloremic metabolic alkalosis, hypokalemia, hyper or hyponatremia), erythrocytosis, hyperproteinemia, hyperlactatemia, Sepsis biomarkers (hypoglycemia, hyperbilirubinemia, hyperlactatemia)
Why do we do a left lateral radiograph first if we suspect a FB?
Don’t want the fluid to enter into the pylorus or the foreign body to get lodged by the FB, so take a left lateral photo first so it’s not gravity dependent
What are the 3 imaging techniques used for SI disease?
Contrast study (barium studies- if they can’t swallow… asipration pneumonia, or if there’s a perforation –> peritonitis), US, CT
Which lateral view (L or R) will you see a large gas filled pylorus on the ventralish side?
Left lateral
Why is fluid therapy important before surgery?
Rehydrate the animal before anesthesia because many FBs can be cut with conservative management, and most animals are at risk for fluid and electrolyte imbalances when undergoing intestinal surgery because they’re often suffering diarrhea, anorexia, vomiting and lose a lot of fluids, entering metabolic alkalosis
Should we use antibiotic prophylaxis before SI surgery and why or why not?
Yes, gram negative and positive bacteria are in the SI (dirty environment), use Cefazolin and injected 30 min before incision. Single dose or continued dose for max of 24 hours.
Which suture types should be avoided and which are ideal for SI surgery?
Multifilament and chromic gut sutures avoided; ideal: those that don’t cause inflammation or potentiate inflammation like monofilament, small sized taper needles, pick ones with relatively long absorption times/maintenance of strength. 4-0 PDS (simple interrupted or continuous), 3-0 PDS for very large dogs
What’s the holding layer of a hollow viscous organ?
SQ
What’s the recommended suture pattern for closing SI?
Single layer appositional (appose Submucosa), inverting patterns narrow the lumen, 2 layer patterns aren’t appositional for submucosa, and everting patterns cause more adhesions.
When cutting out a solitary FB, should we cut aboral or oral to it?
Aboral, cut in the healthy prat of intestine longitudinally on antimesenteric border
What do you do with necrotized intestinal wall?
You resect and anastomose the healthy sections together. Resect it based on blood supply to bowel
What’s the goal of the gambee pattern and when do you use it?
If the mucosa everts while you’re trying to suture it, you can use the Gambee pattern which tries to keep the mucosa on the inside without trying to have too much eversing
What do we do if the intestines are a different size at where you resected?
Cut non=dilated side at a slant, and dilated side straight down, take closer bites on narrower side and farther bites on dilated side.
T/F: you can use staples on resection and anastamosis
False: don’t use staples, they will destroy the intestines and be super irritating
What do you do with the omentum after anastmosis?
Magical bandaid, so do enterotomy –> flush –> throw omentum ontop and protects it
Describe the leak test
normal peristaltis pressures in SI of dogs = 15-25 mmHg, so take a needle and inject some saline, don’t put too hard
