Approach to the small animal Abdomen Flashcards
Indications for Diagnostic / prognostic ExLap?
- Sampling to
get/confirm diagnosis - Culture
- Histopathology
- Cytology
- Visual inspection
What Therapeutic indications for ex lap?
- Haemoabdomen
- Peritonitis
- Mass removal
- Obstruction/Torsion
- Trauma/Hernia
- Calculi
- Congenital
(shunt/ectopic ureter) - Enteral/cystostomy
tube placement - Dystocia/Pyometra
- Sub total colectomy
Indications for preventative Exlap?
Neutering *
Gastropexy
(plication)
Colopexy
Intestinal Plication?
- Previously performed to prevent recurrence intussusception
- No longer advised
Advantages of Open celiotomy?
- Direct visual and tactile inspection
- Good sample collection
- Potential to perform therapeutic procedure
Disadvantages of Open coeliotomy?
- Invasive
- Costs?
- Risk
- GA, pain/morbidity
- Time consuming?
What diagnostics to determine wether surgery indicated ?
➢ Radiography +/- contrast
➢ Get help with interpretation
➢ Serial rads-care with Barium
➢ Risks with aspiration pneumonia/abdominal spills
➢ Ultrasound
➢ Endoscopy
➢ Minimally invasive biopsy techniques
➢ CT/MRI
How else do we avoid unecessary surgery?
- Localise to abdomen-care with spinal pain
- Too unstable to survive GA/procedure
- Total costs (diagnostics and ex lap vs straight to ex lap)
How do we prep owner
» Emotive, costly, outcomes unknown, last resort
»Good communication and informed consent
Pre-op stabilisation of Chronic conditions?
- Co-morbidities
- Clotting
- CVS
- Correct electrolytes
- Correct dehydration
- Parenteral nutrition
Pre-op stabilisation of Acute conditions?
- Intravenous fluid
- Hypovolaemic
- Dehydrated
- Correct electrolytes
What might we find (be prepared for) ?
- Intestinal mass
Biopsy
Enterectomy/anastomosis - Foreign body obstruction
Enterotomy/enterectomy - Intussusception
- Splenic mass
- Liver mass
- Disseminated neoplasia
What do u need ?
- Abdominalretractors
- Suction/lavage
- Multiple haemostats – curved, long
handled - Extra swabs
exposure with Gosset & Balfour
List halstead principles
- Gentle tissue handling
- Meticulous haemostasis
- Preservation of blood supply
- Strict aseptic technique
- Tension free closure
- Accurate apposition of tissues
- Eliminate dead space
What does patient prep involve for ex lap?
- Dorsal recumbency
- WIDE CLIP & PREP – be prepared
- 4 corner draping
- Retract prepuce/catheterise
- Large surgical incision
Describe how to make incision
ex lap
➢ Xiphoid to pubis
➢ Extend incision parapreputial in male dog
* Sever preputial muscle
* Ligate branches of epigastric vessels
How do we start our ex lap?
- Swab count
- Ventral midline skin incisions
-> Sharp -slide cut on smooth
-> Sharply dissect SC tissues & expose LA
Part 2 of Exlap?
- Tent linea alba with forceps
- Stab incision with scalpel
- Reverse blade
➢ Beware bladder, engorged stomach/intestines/uterus,
spleen, mass
➢ Check for adhesions
Step 3?
*Carefully extend incision along linea with scissors or
blade
➢ Tent with fingers/forceps
➢ Reverse/backhand cut with scissors
➢ Avoid rectus abdominis muscle
➢ Long incision
Step 4 ?
- Remove falciform fat
- Abdo retractors
- Moistened laparotomy laparotomy swabs
Describe the systematic approach of abdo exploration
➢ Cranial → caudal vs quadrants
➢ Texture/appearance/location
➢ Abdominal fluid
➢ Gut motility
➢ Presence and appearance/size of Lymph tissues
General things to rememebr when exploring abdo?
- Gentle tissue handling – gloved fingers, moistened swabs, stay sutures
- Avoid tissue desiccation – moistened swabs/saline flush
- NOTE: If trauma/haemorrhage/leakage of GIT contents or dystocia – identify and treat first
What should you inspect in cranial quadrant
➢ Liver – all lobes
➢ Gallbladder (between right medial and quadrate
lobes)
➢ Can express gall bladder to make a judgement
on duct patency
➢ Diaphragm
➢ Spleen and stomach
➢ Duodenum and pancreas (right and left limb)
➢ Kidneys and adrenals
➢ Ovaries and uterus
What to inspect in Caudal quadrant?
➢ Jejunum, ileum and colon
➢ Lymph nodes
➢ Urinary bladder
➢ Prostate
➢Uterinebody
What to inspect in Right quadrant?
- Duodenal manoeuvre
➢ right kidney
➢ adrenal gland
➢ ovary
➢ ureter
How to inspect left quadrant?
- Colon manoeuvre
➢ left paravertebral fossa
What should we do to examine the GIT
*Exteriorise and ‘run through’
*Examine omentum and mesentry
»Keep organs moist with swabs and flush
What to look for in Duodeno-Colic Ligament?
- Often can inspect the colic lymph
nodes here - Common site of obstruction
- Need to break down the
ligament to resect this piece of
intestine
What to do if nothing is found on ex lap?
SAMPLE!
What to sample?
biopsy -> LN, lymph,
Cytology /impression smears -> gallbladder, urine, abdo fluid
Histopath and cyto
- Bact C/S -> Tissues & fluids
How do we Biopsy
- Isolate area of interest & pack with swabs
- Stay sutures for gut
- Close appropriately
- Use appropriate suture M
- Prep samples appropriately (EDTA, formalin..)
- LABEL
What to remember at wound closure?
COUNT SWABS!
- Copious lavage
- Change instrument and gloves if entered a contaminated viscous
How many closure layers?
3
How to close linea alba?
➢Incorporate rectus abdominis muscle sheath
➢Wide bites 0.5-1 cm
➢0.5-1 cm apart
➢Avoid subcut tissues
➢Simple continuous or interrupted
➢Synthetic absorbable
N° of throws?
» For interrupted
* Minimum of 3 throw for multifilament
* Minimum of 4 throws for monofilament
» Continuous
* One throw added to start
* Two throws added to end
Closure fo SC layer?
➢Obliterate dead space and appose skin edges
➢Simple continuous
➢Synthetic absorbable
➢Male dog suture preputial muscle
➢High risk seroma male dog
Skin closure ?
➢Do not overtighten
➢Intradermal, simple interrupted, ford interlocking, staples
Top tips for 3 layer closure
POST OP CARE?
- Analgesia
- Antibiosis if indicated
- Turning if non ambulatory
- Care of catheters, drains, feeding tubes
- Continued monitoring of hydration and fluid replacement/maintenance
- Serial monitoring and exam
- Dependent upon procedures performed
Complications of laparotomy?
- Seroma formation
- Wound breakdown/dehiscence→herniation
- Avoid with good technique and proper post operative rest
- Infection
- Suture reaction
- Adhesions
- Iatrogenic peritoneal fb
➢ COUNT YOUR SWABS
Describe PERITONITIS as complication of laparotomy?
- Caused by abdominal sx (rupture/necrosis of organ, FB penetration, GDV)
- Mortality 50-70%
- Clinical signs
- anorexia/depression, V+/D+, fluid dripping form surgical incison, abdo pain, progresses to shock
- Diagnostics
- bloods – generalised dehydration and infection
- HCT and TP, hypoproteinaemic, hypoglycaemic
- Abdominocentesis and cytology
- Treatment
- antibiotics,supportive care, peritoneal lavage
Give advantages of LaparoSCOPY
- Minimally invasive
- Good visual
inspection - Good biopsy samples
from most organs - Potential to perform
some therapeutic
procedures
Give Disadvantages of LaparosCOPY
- Limited tactile
inspection - Unable to perform
some procedures - Specialists equipment
and training - Costs
- Time consuming?
Laparoscopy uses?
- Ovariectomy (ovariohysterectomy)
- Biopsy
- Liver
- Cholecystectomy
- Lap- assisted gastropexy
- Lap- assisted cyrptorchid castration
- Lap- assisted cystotomy?
- Detection of small lesions/assessment of disease
Laparoscopy technique?
» Wide clip and prep
» Abdomen inflated with CO2 using veress needle (blind)
» Trocar/cannula inserted for scope (blind)
