Decision Making in GI Obstruction Flashcards
what is a gastronomy
incision in stomach
what is enterotomy
incision into intestine
what is enterectomy
removal or portion of intestine
how do you limit contamination in GI surgery (8)
- isolate using moistened swabs
- exteriorize intestine when possible
- dirty area of trolley
- change gloves + intruments after closed GI tract
- perform local lavage
- perform general lavage
- milk contents away from incision lines
- occlude intestines: doyen intestinal clamps, assistants hands
what forceps should you use to hand the intestines
atraumatic forceps
plain thumb forceps
debakey vascular forceps
what do you need to do when you are suturing the intestines
engage the submucosa
fibrous suture holding strong layer
what suture materials are appropriate
- monofilament
- synthetic
- absorbable
must be synthetic material
cat gut matieral is not acceptable –> it will be digested by proteases
poliglecaprone 25 (monocril)
glycomer 631 (biosin)
polydioxanone (PDS 2)
what suture patterns can be used
appostitional patterns
simple interrupted or continuous
how far apart should simple interrupted sutures be
3mm bites 3mm apart
what is the cushing pattern be used for
invert seromuscular layer in the stomach
produces early serosal seal
what are the benefits of serosal seal (5)
- reduce leakage
- increase blood supply
- speed up healing
- increase drainage
- increase local host defences
what is an omental wrap
wrap omentum around intestine
adhere to incision line and bring in a good blood supply and drain material away
don’t necessarily need to suture into position but you can put a tacking suture proximally and distally
when should you feed postoperatively
early feeding recommended
why is early feeding recommended
- little distention of intestine with feeding
- water tight seat
- enteral feeding crucial for mucosal health
what are common presentations of gastric foreign bodies
- incidental finding
- obstruction: intermittent or persistent vomiting
what are the treatment options for gastric foreign bodies (3)
- induce emesis
- endoscopic retrieval
- gastronomy
where is a gastronomy done
between the lesser and greater curvature
in the body of the stomach
how do you begin your incision into the stomach
stay sutures to lift the area you want to incise up
the liquid sits at bottom and gas at the top
easier to control contamination
what scissors should you use to extend your incision in a gastronomy
metzenbaum
mayo scissors are too blunt and will crush tissue
how do you close a gastronomy (2)
- first layer: simple continuous mucosa and submucosa
- second layer: cushing in seromuscular layer
what is a non viable area of intestine
wall thinning
green
grey
black
what is a compromised area of intestine
avulsed vessels
red
hemorrhagic
what is viable intestine
active hemorrhage from nick
pulse
peristalsis
what are key things to remember when performing an enterotomy
- do not incise over the foreign body as this area is compromised
- extend incision to avoid stretching and tearing as foreign body is removed
- use instruments to handle foreign body
- sutures must engage the submucosa
describe how to perform an enterotomy (5)
- pick site proximal or distal to foreign body
- linear incision
- antimesenteric surface
- no 11 blade
- extend with scapel or metzenbaum scissors
how is an enteronomy closed
submucosa is holding layer
simple, full thickness appositional pattern (interrupted or continuous)
how do you perform a leak test in enterotomy
occlude intestine
25 guage needle
5ml saline
gentle pressure
how do you perform an enterectomy (5)
- identify areas to resect including healthy margin –> make incision between two arcuate vessels
- ligate vessels
- incise mesentery
- curshing clamps on portion to excise
- non crushing clamps on portion to suture
how do you close an enterectomy
suture 1: mesenteric border
suture 2: anti-mesenteric border
fill in between: 3mm apart
close mesentery
how do you deal with luminal disparity
adapt narrower end of intestine so it matches the larger loop
extend incision on anit mesenteric surface
so length along the intestine matches the loop
get a triangular edges and can help to trim those off
what is an intussesception
proximal telescoping inside the distal loop
causes obstruction, adhesion and pressure buildup and vascular comrpomise leading to necrosis
when are intussusceptions common
in puppies and kittens
spontaneous
possibly secondary to worms or enteritis
where is the most common location for intussusceptions
jejunocolic at ileocecocolic junction
how do you diagnose an intussusception (3)
- clinical signs in young animal
- palpable sausage in abdomen
- ultrasound distinctive
how do you treat an intussusception (2)
- reduce intussusception +/- enteroplication in young patients
- enterctomy if there is non viable tissue or in old patients
how do you reduce the intussusception
squeeze base of intussusception distally whilst applying cranial traction
when should you perform an enterectomy with an intussusception (4)
- adhesions prevent reduction
- tissue non-viable
- tissue tears
- neoplasia
what is an enteroplication and what are the risks
suture adjacent loops of small intestine together on antimeseteric surface
prevents recurrce but there is risk of perforation and death
reserve for reccurent cases
how do linear foriegn bodies travel through intestines
usually gets trapped at base of tongue
string becomes taught in intestine
intestines bunch up around FB
string cuts into mesenteric border
what can linear foreign bodies cause
perforation
peritonitis
death common
