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522 MT1 > Abdominal Sx 1 > Flashcards

Abdominal Sx 1 Flashcards

1
Q

what is an ex lap in proper terminology

A

exploratory celiotomy
it is a surgical incision. into the abdominal cavity, routinely along the middle

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2
Q

3 indications for an exploratory surgery

A

diagnostic, therapeutic, preventative

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3
Q

7 Halstead’s principles of surgery plus 4 more principles

A

strict asepsis
gentle tissue handling
effective hemostasis
preserve blood supply
minimize tissue tension
accurate tissue apposition
eliminate dead space
prevent tissue desiccation
appropriate surgical access
appropriate use of medications
don’t leave shit behind

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4
Q

what must you be able to see in an ex lap / midline celiotomy

A

visualize all the organs
meaning you need to surgically prepare for a xiphoid to pubis incision, and prep prepuce

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5
Q

what must you count in any surgery

A

SPONGES/SWABS

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6
Q

what is the HOLDING LAYER of the abdomen

A

EXTERNAL RECTUS SHEATH (aka external leaf of rectus sheath)
you need to include this layer in your sutures

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7
Q

what is between the internal leaf and external leaf of the rectus sheath

A

rectus abdominis muscle

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8
Q

what part of abdomen do you make a stab incision facing upwards, palpate for adhesions, and then use Mayo scissors to extend incision cranially and caudally

A

linea alba

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9
Q

why bother mitigating dead space

A

more dissection = more dead space = increased risk of seroma, infection, tissue necrosis, and dehiscence

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10
Q

in abdominal surgery, when do you leave the falciform ligament [connects liver and diaphragm] and when do you remove it

A

leave it for a caudal incision (eg. cystotomy)
remove it when performing a cranial and middle midline incision (better visualization and mitigates risk of falciform necrosis)

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11
Q

when lavaging prior to abdominal closure, what should you add to lavage fluid?

A

don’t add anything - no advantage to adding antibiotics; adding chlorhex or povidone iodine may inhibit macrophages
and only lavage if needed, using WARM sterile saline, and suctioning away prior to closure

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12
Q

what suture material and pattern to use for abdominal SQ closure

A

rapidly absorbable suture (Monocryl, Biosyn)
3-0 or 4-0 depending on patient size
simple continuous, tacking down q3-4 bites, besides the linea

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13
Q

what suture material and pattern to use for abdominal SKIN closure (assuming not using intradermal)

A

non-absorbable monofilament
(eg. nylon, Prolene)
simple interrupted or cruciate pattern, but continuous pattern if small patient, unstable
4-0 or 3-0

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14
Q

what suture material to use for abdominal INTRADERMAL skin closure

A

rapidly absorbable monofilament (Monocryl, Biosyn) (same material as for SQ closure)

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15
Q

what are these muscles

A
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16
Q

should you suture the peritoneum? why or why not

A

no
increases adhesion risk, no holding strength, and doesn’t contribute to wound healing anyway

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17
Q

what suture type should you use for linea alba

A

strong, long lasting, absorbable monofilament suture (PDS)
simple interrupted - size 3-0, 2-0, or 0
or simple continuous - size 2-0, 1-0, 0, or 1
5-10 mm bites, or 10 mm if off midline
remember to always include the external rectus sheath (holding layer)

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18
Q

can you use catgut for linea alba closure

A

NO, it is inflammatory and increases risk of dehiscence

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19
Q

can you use STEEL for linea alba closure

A

NO, it increases adhesion risk

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20
Q

can you use non-absorbable braided suture for linea alba closure

A

NOT RECOMMENDED because it can cause sinus formation

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21
Q

why can’t we use Monocryl, Biosyn, or Vicryl for linea alba closure

A

NOT RECOMMENDED because they lose 50-80% tensile strength in 2 weeks

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22
Q

how often to tack the SQ layer suture, and where to tack

A

q3-4 bites, tack besides linea suture line

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23
Q

when is perioperative antibiotic therapy used in abdominal surgery

A

most abdominal surgeries get preoperative antibiotics
(this means starting within 30 min of cutting skin and stopping once procedure is done/within 24 hours)

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24
Q

when is post-operative antibiotic therapy warranted in abdominal surgery

A

for contaminated surgeries
intestinal, colonic, septic, abscesses, etc.
choose appropriate one for strain, anticipated organisms

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25
Q

when is post-operative antibiotic therapy NOT warranted in abdominal surgery

A

surgeries <1-1.5h that maintain aseptic technique and minimal tissue trauma and none of the following:
NO entry into hollow viscous, NO contamination, NO underlying skin disease

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26
Q

5 things to monitor surgical site for 2-3 times daily

A

redness, swelling, discharge, pain, dehiscence

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27
Q

how long to restrict activity following non-laparoscopic abdominal surgery

A

2-4 weeks

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28
Q

ideally, should you perform a lymph node biopsy or an intestinal biopsy first (in same patient)

A

ideally do the GI biopsy last, and then swap your gloves and instruments prior to closure bc it is clean-contaminated now

29
Q

3 types of liver biopsies

A

guillotine
biopsy punch
laparoscopic

30
Q

2 types of lymph node biopsies

A

whole node or incisional biopsy
can also do cytology

31
Q

what abdominal things do we never biopsy

A

adrenal glands
major vasculature

32
Q

explain external vs internal hernia and give a couple examples of each

A

external = protruding organ is visible on outside of body, as a defect of abdominal wall
- eg. umbilical, inguinal, scrotal, perineal, failed body wall closure, traumatic body wall hernias.

internal = not visible on outside of body
- eg. diaphragmatic, mesenteric rents not closed at time of surgery, also perineal

33
Q

what are the components of a hernia

A

ring = border of defect
+/- sac = layer of tissue containing protruding organs

34
Q

how to diagnose a hernia

A

history, clinical signs, imaging (rads, U/S, CT) visualize/palpate if external

35
Q

which size of hernia is most concerning: very small, medium size, or very large

A

medium size = large enough for visceral entrapment; risk of tissue strangulation is an emergent concern
if very small or very large, rarely causes emergent issues

36
Q

how to repair hernia

A

abdominal wall appositional repair with a monofilament, or (rarely needed) mesh
note increased anesthetic risk with diaphragmantic hernia

37
Q

what is peritonitis? give an example of primary peritonitis and of secondary peritonitis

A

peritonitis = any inflammatory process involving peritoneum
primary: FIP in cats
secondary: sequela to other processes, can be septic (eg. bowel perforation or dehiscence, penetrating wounds) or aseptic (eg. pancreatic enzymes, diffuse neoplasia)

38
Q

patient presents with fever, depression, anorexia, abdominal pain, nausea, vomiting, diarrhea. bloodwork shows leukocytosis with left shift, hypoglycaemia, and hyperlactatemia. abdominal rads show effusion (lack of serial detail) and pneumoperitoneum.
cytology image of peritoneal fluid is shown. what do you diagnose?

A

septic peritonitis

(why: note non-specific C/S. note fever and leukocytosis are note always present. PNEUMOPERITONEUM: free abdominal air can be normal 3 weeks post-sx, but pt is not post-sx. ABDOMINAL EFFUSION is also present.
cytology shows DEGENERATIVE NEUTROPHILS with INTRACELLULAR BACTERIA)

39
Q

peritonitis blood chemistry and peritoneal fluid: what findings are suggestive of septic peritonitis?
(for a patient who is NOT post-op)

A

glucose: blood hypoglycaemia; blood:fluid glucose difference >20mg/dL supportive of septic peritonitis (peritoneal glucose <50 mg/dL)

lactate: blood hyperlactatemia; blood: fluid lactate difference below -1/5 to -2.0 mol/L (peritoneal lactate >2.5 mol/L)

+/- leukocytosis with left shift or neutropenia

also do a culture

40
Q

peritonitis blood chemistry and peritoneal fluid: what findings are suggestive of bile peritonitis?
(for a patient who is NOT post-op)

A

bloodwork: elevated bilirubin, alkaline phosphatase, alanine transaminase

bilirubin: peritoneal fluid > 2xserum

also bile crystals

41
Q

peritonitis blood chemistry and peritoneal fluid: what findings are suggestive of uroabdomen?
(for a patient who is NOT post-op)

A

bloodwork: elevated BUN, creatinine, potassium
creatinine: peritoneal > serum
K+ peritoneal > serum

42
Q

basics of peritonitis treatment

A
  • aggressive patient stabilization: IV fluids, pain meds, BROAD spectrum antibiotics, +/- vasopressors/ionotropes, +/- blood products
  • surgery to remove inciting cause
  • lavage abdomen
  • drain peritoneal cavity with closed suction drain
43
Q

you are suspicious of peritonitis in an unstable patient.
which should you perform first: bedside U/S, other imaging, or patient stabilization

A

bedside diagnostics first, then patient stabilization, then imaging.

44
Q

peritonitis patient: can clients do post-operative management at home?

A

NO, this is a 24h tertiary care facility job
need hours monitoring of vital parameters, IV pain meds and antimicrobials, drain management, and possibly other intensive things

45
Q

prognosis of peritonitis

A

guarded at best
20-80% mortality

46
Q

what are 2 categories of abdominal trauma

A

penetrating trauma: direct perforation/laceration of bowel, vasculature, or other organs
blunt trauma: immediate tears or vascular compromise to organs

47
Q

how to diagnose abdominal trauma

A

abdominal rads: free gas in abdomen = penetrating wound or ruptured hollow viscous

diagnostic peritoneal lavage: if bacteria or vegetative manner = GIT perforation

clin and lab findings are not good predictors

48
Q

should you treat abdominal trauma with surgery

A

sometimes
yes, if intestinal or urinary perforation
some recommend exploratory for all penetrating abdominal wounds

49
Q

gastrotomy: what suture pattern to use, and which layers of the stomach do you go through

A

1st layer: MUCOSA/SUBMUCOSA or full thickness for hemostasis, use appositional pattern
2nd layer: muscularis/seorsa, use appositional or inverting
use PDS

50
Q

what is GDV

A

GASTRIC DILATATION (air accumulates in stomach)
and VOLVULUS (gastric malposition 180-270 degree rotation)

51
Q

consequences of GDV

A
  • gastric wall ischemia, necrosis, performation
  • local splenic effects: hemorrhage, congestion, possibly torsion
  • decrease in venous return and inadequate coronary vessel outflow = obstructive and hypovolemic shock, impaired diaphragmatic function
  • bacterial translocation from poor GI perfusion
  • reperfusion injury when GDV corrected
52
Q

name a few risk factors for GDV

A
  • large/giant breed dog
  • deep chest
  • stress
  • feeding: large amount, eating fast, only one type dry food, post-prandial exercise
  • increased age
  • intact male
  • familial tendency
  • previous splenectomy
53
Q

name a few of the (variable) C/S for GDV

A
  • distended abdomen, splenomegaly, abdominal discomfort, restlessness, hyper salivation
  • poor pulse quality, long CRT, tacky mm, shock/collapse, dysrhythmia
  • tachypnea, dyspnea
54
Q

name a few DDx for GDV

A

gastric dilatation alone
torsion of spleen or mesentery
trauma: diaphragmatic hernia
abdominal mass
peritonitis
PCE with heart failure

55
Q

bloodwork findings for GDV? which component is prognostic?

A

hemoconcentration, thrombocytopenia, elevated ALT and bili, electrolyte abnormalities
lactate serial/trend is prognostic

56
Q

besides bloodwork findings, what other initial diagnostic findings for GDV in a non-stable patient

A

arrhythmias esp. VPCs and VT
trocharization

57
Q

how to stabilize GDV

A

AGGRESSIVE IV FLUID treatment is most important (2 IV catheters, forelimbs better because CdVC is being compressed by stomach, crystalloids)
decompression with trocharization preferred, orogastric intubation if not resistance
analgesia if stable (fentanyl or methadone titrated)
lidocaine bolus for VPCs if HR > 260 bpm, hypotensive, R on T, or polymorphic QRS

58
Q

once stable, what imaging to perform for suspected GDV dog

A

right lateral abdominal radiograph: see gas distended stomach with compartmentalization
if needed, DV view next

59
Q

briefly describe surgery to correct GDV

A
  • emergency surgery
  • long midline celiotomy, careful incision into linea
  • detorse stomach by grasping pylorus or proximal duodenum, pulling ventrally, while pushing funds dorsal and to left; can use orograstric tube for decompression
  • assess gastric viability: DORSAL and ventral, and CARDIA common area of necrosis; gastrectomy if needed
  • assess rest of abdomen, especially SPLEEN and look for FB or masses
  • perform gastropexy
60
Q

3 indications for splenectomy in a GDV dog

A

torsion of vascular pedicle
lack of palpable splenic arterial pulses
if congested initially and shows no improvement by end of surgery

61
Q

what are 3 indications for gastropexy? which side, left or right?

A

left - hiatal hernia
right - GDV or prophylactic pexy
prophylactic gastropexy specifics: (lifetime risk of GDV for predisposed dogs is 4-37% and there is 29X decreased mortality rate vs dogs without pecs, so consider gastropexy, especially if you are already in the abdomen)

62
Q

tube, circumcostal, incorporating gastropexies, and gastrocolopexies are not recommended.
what 2 types of gastropexies ARE recommended?

A

incisional gastropexy (goes through transverses abdomens, serosa, muscular, and then 2 suture lines)

beltloop gastropexy (more challenging; create gastric flap and pass through T.A. loop, then suture gastric flap to gastric wall)

both have excellent outcomes

63
Q

describe post-op management for GDV

A

continued ECG monitoring for VPC and VT
24 hour care facility for intensive monitoring and tx

64
Q

most common gastric neoplasias in cats and dogs

A

dog adenocarcinoma
cat lymphosarcoma
other: leiomyosarcoma, fibrosarcoma

65
Q

which are emergencies:

type I sliding hiatal hernia
type II paraesophageal hiatal hernia type III combination of I and II
type IV herniation of abdominal contents through esophageal hiatus
gastroesophageal intussusception

A

type IV and gastroesophageal intussusception

66
Q

how is hypertrophic pylorogastropathy diagnosed

A

U/S and CT, endoscopy, sometimes barium radiographs

67
Q

how is hypertrophic pylorogastropathy treated

A

pyloroplasty (to remove affected tissue and widen pylorus; a referral procedure)

68
Q

describe congenital vs acquired hypertrophic pylorogastropathy

A

congenital: usually muscular later, brachy dogs <1 year
acquired: mucosal or mucosal and muscular layers, small dogs

522 MT1 (21 decks)

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