Gastrotomy, Enterotomy and Enterectomy Flashcards
Define Gastrotomy
the operation of cutting into the stomach
Define enterotomy
the surgical cutting open of the intestine
Define enterectomy
a surgical procedure used to remove a portion of the intestine
Discuss the vasculature of the stomach
Stomach very well vascularised organ – supply down greater curvature and left and right and venous drainage down less curvature
Anti-mesenteric and mesenteric blood supply – but doesn’t have its own mesentery like the small intestine
What is the bacterial load like in the stomach?
Is this a concern when doing a gastrotomy?
Low bacterial load – more worried about acidic contents getting into abdomen rather than the bacterial content
If its full of food and contaminate the abdomen with this, not the best
But if empty and we operate – low risk organ for contamination bacteria wise
How do you approach a gastrotomy?
How can you keep the stomach in place once exteriorised?
Ventral midline celiotomy
Stay sutures put in and packed off with swabs to keep it in place
When doing a gastrotomy, where do you make the incision?
Usually incision is made longitudinal along the long axis, so as to avoid the blood vessels – can see vessels coming in on each side
What is the purpose of stay sutures and swabs when doing a gastrotomy?
Stay sutures put in place and packed with swabs
So surgery is performed outside peritoneal cavity, so minimising risk of contamination
How do you close the stomach up following a gastrotomy?
Tendency to slip into 2 separate layers, so very obvious sub mucosal and serosal muscularis layer – commonly close in 2 layers – simple continuous or simple interrupted
Could so single layer if you wanted, but usually do a 2 layer closure as presents itself as 2 very obvious layers
If you have a foreign body in the intestine, what is the oral and aborla part of the small intestine like with regards to the locations of the FB?
If we have obstruction in intestine, the oral side of it, will be distended with fluid as the fluid cannot get through. Commonly on the oral side of the obstruction, it will be distended
Aboral side – distal to FB, it may be empty
When removing a FB from the small intestine, where do you make the incision?
Pack bowel out of abdomen
Make incision on anti-mesenteric border
With a FB, there is often lots of luminal ingesta at the ORAL side of the FB.
What do you do with this and why?
And what is the best method?
Lots of luminal ingesta that was proximal, want to remove this, if you leave in – will commonly mean the bowel will remain in ileus and wont restore normal function – just like a colic – generally empty the contents to remove chance of endotoxemia and encourage bowel to start working again post surgery. Usually put secondary draping in to stop it contamination – drain onto other sterile area away from surgical site – try to do OUT AND AWAY from remaining testing and from incision and peritoneum. Remove drape and reglove
How do you close the bowel?
Single layer
FULL thickness
When doing an enterectomy, how many and where should you place the clamps? What types?
The piece being removed is between the 2 inner clamps. The 2 inner ones can be crushing clamps as we are removing that part anyway! 4 clamps in total usually.
Clamps outside of this should be atraumatic – just stopping contents entering surgical sites
Where does the blood supply come from to the small intestines?
What does this mean when cutting out a section of bowel?
Blood supply comes in through jejunal arteries and then another BV that anastomoses on anti-mesenteric border. Vessels come in and almost 90 degrees to long axis of the bowel
So when we cut the bowel, usually cut at an angle, so that the anti-mesenteric border is more likely to have a blood supply to it – means it is much more likely we are not going to compromise the blood supply
What happens to the longitudinal smooth muscle of the small intestine when you cut into it?
What does this mean for sticking back together - what can you do?
Contraction of longitudinal smooth muscle will evert out the mucosal surface – balloons out at you when you cut it
If you want to put these 2 edges back together, makes it difficult to bring the 2 ends together so usually trim it off, curved Metzenbaum’s. Trim down to submucosal, so you can put them together nicely
After doing an enterectomy, how can you stitch it back together?
Usually simple continuous closure of bowel, nothing wrong with simple interrupted but requires more knots!!
2 bits of suture material, one full thickness through mesenteric and anti-mesenteric border
How should you close the ‘rent’ of the mesentery?
Made hole in mesentery – need to close this
Close this with simple continuous pattern again and using mesentery to close it
Be careful as the mesentery can fold away – just be careful you don’t include vessels you have saved
After you have done the enterectomy and stitched intestines back together etc, what should you do next?
If made hole into anything = will omentalise it – it will bring in factors that will encourage healing, blood, oxygen, inflammatory cells, neutrophils, macrophages, cytokines etc.
Drape it over site of incision
May tack it down on occasions – tack through mesentery rather than onto bowel itself as could cause problems with motility
What is the complication of putting the omentum over the root of the mesentery before it has been closed (like shown in the picture)?
This is putting omentum over the rent of the mesentery (hasn’t been closed yet), rob doesn’t like this technique as the omentum can bunch up and get external extra luminal bowel constriction
Drape omentalise is better!!
Picture shows how it has bunched up when putting it through the rent
Dehiscence and anastomosis and peritonitis is a complication of these types of surgery.
When is it most likely to occur?
What should you do to treat it?
- Likely to occur somewhere between day 5 and day 7 on average, somewhere in first week!
- Tap it and US it, run full bloods etc. if we are worried.
- Do some in house cytology or may send away for C&S – don’t wait too long with these cases! Better to be more oppressive – if animal is stable enough for anaesthetic, often a good idea to go in and have a look! If all okay, may well be preferential rather than waiting as then the dog may be too ill to cope with the GA
- Hit hard with antibiotics! Gram positive and negative spectrum.
Where is the most common place for a wound to break down?
At the commisures (ends of the wounds)
If you go back into a dog that has had an enterectomy to find that the wound has broken down and sutures have come undone, what should you do to fix it?
Don’t reclose this at the same site!!! – might need to take out this site and start again with fresh tissue!
How does the normal body have mechanisms to try and stop small bowel torsion?
Mechanisms – there are fixed points in the abdomen to stop them twisting and getting stuck
What is the peritoneum?
Serous membrane of lose connective tissue lining the abdominal cavity, lies beneath the abdominal musculature
What are the two layers of the peritoneum in the abdomen?
- Two layers of peritoneum lining the abdomen. Between these two layers is the peritoneal cavity
- Parietal layer: lines abdominal wall
- Visceral layer: lines abdominal viscera
What is referred to as the serosa, as part of the peritoneum?
Covered by mesothelium; connective tissue and peritoneum are referred to as the serosa
What suspensory structures does the peritoneum form?
- Peritoneum doubles up to form the following suspensory structures: mesentery (from viscera to dorsal abdominal wall), omentum (from stomach to other viscera and ligaments)
Name some intraperitoneal organs
- Intraperitoneal organs: stomach, SI, LI< liver, gall bladder, pancreas, spleen
Name some retroperitoneal organs
- Retroperitoneal organs: behind parietal peritoneum, include kidneys, adrenals, ureters, bladder, part of oesophagus, rectum, ovaries, uterus, aorta and caudal vena cava
Label the blue and purple arrows
- Anti-mesenteric (blue arrow): opposite mesenteric attachment
- Mesenteric (purple arrow): side of mesenteric attachment
What is the mesentery and what does it do?
Mesentery: continuous set of tissues that attaches the intestines to the abdominal wall and is formed by the double fold of peritoneum. It helps in storing fat and allowing blood vessels, lymphatics, and nerves to supply the intestines, among other functions
What is the function of the:
- Mesoduodenum
- Greater mesentery
- Mesocolon
- Mesorectum
- Broad ligament?
- Mesoduodenum: attaches duodenum to abdominal roof, containing right lobe of pancreas
- Greater mesentery: form jejunum and ileum to abdominal roof and contains cranial abdominal artery and vein, mesenteric LNs and mesenteric plexus
- Mesocolon: attaches colon to abdominal roof
- Mesorectum: attaches rectum to abdominal roof
- Broad ligament: mesometrium, mesosalpinx and mesovarium, from ovary, oviduct, uterus, cervix and cranial vagina to dorsal body wall
What is the omentum?
Layers of peritoneum that surrounds abdominal organs and fascia. During development in the region of the stomach, a fold of the dorsal mesogastrium extends into a curtain-like structure called the greater omentum
What is the difference between omentum and mesentery?
Omentum is a fold of peritoneum joining the stomach to abdominal organs, mesentery joins the intestines to the abdominal wall
What is the difference between the greater omentum and the lesser omentum?
- Greater omentum: from greater curve of stomach to dorsal abdominal wall
- Lesser omentum: from lesser curve of stomach to liver
Explain what the following GI ligaments attach:
- Gastrophrenic
- Gastrosplenic
- Hepatoduodenal
- Round
- Suspensory
- Proper
- Gastrophrenic: from greater curvative or stomach to the crura of the diaphragm
- Gastrosplenic ligament: from greater omentum, connecting spleen to the stomach
- Hepatoduodenal ligament: from cranial duodenum to liver, bile duct runs within it
- Round ligament: part fo broad ligament, from ovary to inguinal ring
- Suspensory ligament: from ovary to abdominal wall
- Proper ligament of ovary: from ovary to oviduct
