Gastrointestinal surgery Flashcards
The shape of the stomach depends on its
degree of fill. Empty or moderately filled stomach looks like a V-shaped curved bag.
Significantly filled stomach is more or less spherical.
The lower curved part of the stomach is termed ?
..and the area between the upper part of the esophagus and the end of the stomach is the..?
lower part = greater curvature
the area between the upper part of the esophagus and the end of the stomach =
lesser curvature.
part of the stomach with the least amount of blood vessels
gastric fundus (fundus ventriculi)
Ventrodorsally viewed what parts of the stomach are on the right and left? (2+1)
Right: fundus of stomach (fundus ventriculi)
& corpus of stomach (corpus ventriculi)
Left: pylorus (pylorus)
Stomach wall consists of four layers:
name them inside-out
Mucous membrane
Submucosa (the strongest layer)
Muscular layer
Serous membrane
The stomach has four ligaments that hold it in place:
Hepatogastric ligament (lig. hepatogastricum)
Hepatoduodenal ligament (lig. hepatoduodenale)
Gastrosplenic ligament (lig. gastrolienale)
Gastrophrenic ligament (lig. gastrophrenicum)
Which gastric ligament is cut most often during surgeries?
Hepatogastric ligament
(lig. hepatogastricum)
Stomach blood supply?
Celiac artery (a. celiaca) supplies the stomach with blood.
This artery starts from abdominal aorta in between lumbar and diaphragmic regions.
It is a relatively short blood vessel (1–2 cm).
In dogs, this artery is divided into three blood vessels:
Splenic artery (a. lienalis)
Left gastric artery (a. gastrica sinistra)
Hepatic artery (a.hepatica)
In dogs, the celiac artery is divided into three blood vessels:
Splenic artery (a. lienalis)
Left gastric artery (a. gastrica sinistra)
Hepatic artery (a.hepatica
The most important gastric arteries to remember for the exam?
right gastric & gastroepiploic
Omenta are
the ligaments of abdominal organs. They, to a greater or lesser extent, contain adipose tissue.
Omentum is…
(3 features)
a mesenterial membrane that has very intense blood and lymph supply, as well as
angiogenic, immunogenic, and
adhesive features.
Functions of omenta (6)
Hold the stomach and other abdominal organs in place.
Thanks to numerous blood vessels, function as blood depositaries.
Function as thermal insulators of abdominal organs.
Closes the wounds passing through abdominal wall.
Produces and resorbs abdominal fluids.
Indirectly regulates blood pressure.
Main principles of gastric surgery. (3)
Compared to other parts of gastrointestinal tract (GIT), the number of bacteria in the stomach is significantly
smaller.
Perioperative use of antibiotics is indicated in gastric surgery.
The application of preventive antibacterial therapy depends on the particular case.
Main principles of gastric surgery,
Access. (3)
Commonly, ventral median laparotomy is used, where the incision starts from sternal manubrium and continues till the umbilicus.
Balfour retractors are usually used for better visualization of the stomach.
Paracostal laparotomy is an alternative access method (is rarely applied).
Main principles of gastric surgery,
Minimizing contamination risks. (4)
The stomach is isolated from the laparotomy wound with large moist gauze sheets.
Fixating sutures should be placed in the corners of the presumable incision site (2–0, 3–0 monofilament with atraumatic needle).
Different sets of instruments should be used for clean and clean–contaminated parts of the surgery!
Local lavage using NaCl.
Main principles of gastric surgery:
Closing gastric wounds. (3)
1st layer: mucous membrane is closed with simple continuous suture.
2nd layer: submucosa, muscular layer, and serous membrane are closed with intestinal suture (inverted Cushing, Connell, or Lembert suture patterns).
Omentalisation!
What is omentalisation in surgery?
a surgical technique in which the omentum, a fatty tissue that drapes over the abdominal organs, is mobilized and placed into a different area of the body to aid in healing or treatment of a particular condition.
The omentum has remarkable healing properties due to its rich blood supply, lymphatic drainage, and immunological functions. It can promote tissue regeneration, reduce infection, and improve circulation.
Main principles of gastric surgery,
Choice of suture material: (2)
Use Absorbable monofilament:
e.g. polydioxanone,
polygliconate,
polyglicapron 25.
Thickness:
4–0 to be used in cats,
3–0 in small dogs,
2–0 in large dogs.
Gastrotomy Indications: (3)
Removal of foreign bodies from the stomach.
Gastric ulcers.
Removal of gastric neoplasias.
NB in case of biopsy, you always need all 4 layers!
Gastrotomy Patient preparation: (3)
24–hour fasting (pref. min. 6h)
Dehydration will basically always be present in these patients.
Preoperative antibacterial therapy 2 hours before surgery.
In Gastrotomy, The animal is placed and fixed on its back.
The abdominal wall is opened along the
median line between xiphoid and umbilicus.
The omentum is carefully pushed to the side and the stomach is taken out of the wound to the greatest possible extent.
How is the stomach held in place during gastrotomy? (3)
Fixating sutures are placed at both ends of the incision in order to prevent retraction.
The needle must only penetrate serous membrane layer though.
The wound and the area around it are covered with sterile sponges to avoid contamination.
In Gastrotomy, the incision is made between (3)
the greater and lesser stomach curvatures in a less vascularized place.
Gastric contents is removed and gastric wall is examined.
Gastric wall is closed with a two–layer suture.
Pyloromyotomy and pyloroplasty:
The aim of pyloromyotomy and pyloroplasty surgeries is to..?
Indications for this surgery?
increase the diameter of the pylorus.
The procedure is used as a surgical solution for chronic pyloric mucosal hypertrophy or pyloric stenosis.
Both procedures should be performed with precautions, very carefully, because surgical failures and errors are particularly complicated to rectify.
The least complicated method for pyloromyotomy is called..
Fredet-Ramstedt pyloromyotomy.
The goal of a pyloromyotomy is to cut the thickened muscle of the pylorus, relieving the obstruction while preserving the integrity of the stomach and intestinal linings. The effect of the procedure is frequently only temporary.
A Longitudinal incision penetrating serous membrane and muscular layer is made into a less vascularized area of
ventral pylorus. Mucous membrane should remain intact (in case of injury, it is closed with sutures).
This split allows the muscle to relax and the channel between the stomach and small intestine to widen, improving food flow.
Describe the Heineke-Mikulicz pyloroplasty.
Simple method
Longitudinal incision is made into pyloric ventral surface.
The incision goes through all the layers.
Fixating sutures are placed in the middle of the incision on both sides of the wound.
The wound is closed transversally with simple continuous suture.
Suture material: 2–0 or 3-0 resorbable monofilament.
“open long but close horizontal -> increases the diameter of the pylorus”
Describe the Y-U pyloroplasty.
This method widens…
most of the lumen of the pylorus.
The procedure starts with a longitudinal incision (“leg”) in the ventral part of pylorus.
First, the incision only penetrates through serous membrane. The incision goes further and splits into two incisions going parallel to greater and lesser curvatures (“shoulders”).
Makes a Y–shaped incision.
The corner between the „shoulders“ cannot be too sharp and narrow, as it can result in necrosis.
All the parts of the Y-shape incision (leg and shoulders) should be of the same length.
When the first incision through serous membrane is made, the following incisions go deeper and penetrate through
muscular level and mucous membrane.
Severely hypertrophied mucous membrane can be removed.
The closing of the top of the gastric wall starts at the duodenal end of the incision. The incision is closed with simple interrupted suture.
Thus, a Y – shape incision turns into a U – shape one. The suturing continues in both directions
what is this method
Y-U pyloroplasty
Intestinal obstruction is a frequently occurring pathology in dogs, cats, rabbits,
or rodents.
Can be caused by Foreign bodies, invaginations, neoplasias, strictures.
All types of obstructions may cause both local changes of intestine as well as systemic reactions.
Intestinal fluid contains a lot of
potassium, natrium, and hydrochloric acid.
Thus, vomiting out intestinal fluid causes hypochloremic hypokalemic metabolic alkalosis.
In Obstruction cases, Changes in an organism are, to a major extent, related to
fluid balance: excessive fluid secretions into the lumen of intestine; malabsorption of water and water-soluble substances; fluid, electrolyte, and acid–alkali balance disorders; proliferation and translocation of intestinal microflora.
“flocculant fluid”
How to gauge whether the intestines are excessively distended or just plain distended? (e.g. estimating when to proceed to surgery)
On radiographs: Measure the diameter of the small intestine and compare it with the fifth lumbar vertebrae’s base (most narrow part of it).
Rule is that the SI diameter should not exceed 2 x the vertebral body width.
Do not measure the cecum or colon, its useless.
identify
necrosis due to intestinal /mesenterial torsion
identify the area
ileocolic junction
impactions in this area are common in horses
Main principles of intestinal surgery
Choice of suture material.
It depends, but Typically Synthetic resorbable monofilament (polyglicapron, polydioxanone, polyglyconate).
Synthetic non-resorbable monofilament (nylon, polypropylene) might be utilized at times.
possible to use multifilament but it may induce contamination.
All suture materials induce inflammatory reaction of the intestinal wall, however, the one induced by multifilament is usually more severe.
Main principles of intestinal surgery,
Submucosa closure? (4)
Submucosa is the strongest layer of intestinal wall. Correct closing of submucosa guarantees fast and efficient healing.
In case of insufficient contact of submucosa edges, the wound heals more slowly and less efficiently. The contact of submucosa edges is better if a one–layer suture is used.
A two–layer suture may result in avascular necrosis in the upturned tissue parts and prolonged healing period.
Only inverted Schmieden, Cushing, or simple continuous suture types are used.
Enterotomy means
opening part of the intestine e.g. part containing a foreign body which is taken out through the wound and isolated from the wound with sterile gauze.
Describer removal of an FB through enterotomy.
The part of the intestine intended to be cut, is emptied to both sides using fingers, and intestinal clamps are placed for 5–7 cm on both sides of the operation site to prevent flowback of intestinal contents.
The intestine is opened longitudinally on the side without mesentery above the foreign body or next to it (scalpel number 11). The length of the incision should allow for easy removal of the foreign body. If necessary, the incision is lengthened using Metzenbaum scissors.
After the removal of the foreign body, the edges of the enterotomy wound are rinsed with saline and closed with a one–layer simple continuous suture.
Leak testing with saline is useless according to Nick.
Describe Intestinal resection and anastomosis.
In order to be certain that anastomosis is performed on healthy and viable parts of the intestine, 3–4 mm of healthy intestinal wall should be removed together with the pathologically changed segment.
During the procedure, it is essential to keep mesenterial edge of intestinal segment longer than anti-mesenterial
edge.
The moving intestinal segment is raised out of the wound and, in order to prevent contamination, isolated from the rest of abdominal cavity using sterile swabs.
Mesenterial blood vessels supplying this segment are ligated.
The mesentery is cut through in the places where blood vessels are ligated; an attempt to preserve as much of the mesentery as possible should be made.
Fingers or Doyen’s intestinal clamps are used to isolate the segment of intestine.
What is the preferred method for intestinal anastomosis?
Describe how to do it?
End–to–end sewing is the preferred method.
The ends located between intestinal clamps are placed next to one another with their open ends towards the surgeon, and the intestinal edges located next to each other are joined starting from the mesenterial edge (simple interrupted suture).
The corners of the intestine are sewn together at the anti-mesenterial edge.
Afterwards, intestinal edges are closed on both sides using simple interrupted suture or simple continuous suture.
NB Mesentery is closed using simple continuous suture.
Describe Intestinal anastomosis when the ends’ sizes don’t match.
The ends of the intestine are joined side–to–side if the diameters of the ends are significantly different. But this method is rarely used nowadays.
Other option if incising longitudinally on the smaller one and cutting off excess corners created such as in image.
Both ends of the intestine are closed with a two–layer suture (simple continuous suture, Cushing suture).
Intestinal resection and anastomosis:
Describe Stapling of intestinal ends.
Intestinal ends may be joined using gastrointestinal anastomosis stapler and thoracoabdominal stapler.
Quick and simple method
Requires expensive equipment
Stapling of intestinal ends:
Two intestinal ends are placed side by side next to one another (anti-mesenterial edges contact).
The legs of a GIA–stapler are placed in each intestinal segment and anti-mesenterial edges are pressed together.
GIA–stapler cutter is activated creating connection points between two segments.
TA–stapler is placed on the ends hermetically closing them. The free edges of the ends are cut off
Thoracoabdominal stapler
plication due to linear foreign body
Describe Linear foreign body surgery.
Locate the FB
The process of linear foreign body removal via enterotomy starts in the proximal part of gastrointestinal
tract - start with gastrotomy.
In order to remove linear foreign body from the intestine, several enterotomy incisions are made. 2-4 incisions commonly but even more sometimes.
An attempt to remove linear foreign body through only one incision may severely damage or perforate intestinal wall.
Enteroplication is
Fixating intestinal parts to one another. It is used to treat and prevent intestinal invagination.
After correction of invagination or enterectomy, intestinal parts are placed side by side in loops trying to avoid occurrence of any sharp bends.
It is essential to appropriately fixate jejunum and ileum. It is not necessary to fixate duodenum as invagination rarely occurs in this part of intestine.
When intestinal parts are evenly placed in loops side by side, they are sewn together with simple interrupted sutures using resorbable monofilament.
The sutures are placed between mesenterial and anti-mesenterial edges.
The sutures penetrate serous membrane, muscular layer, and submucosa
intestinal invagination or intussusception
enteroplication
involves arranging the small intestine in folds and then suturing it in this arrangement so as to prevent intussusception.
