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Small Animal Surgery > Intestinal Surgery > Flashcards

Intestinal Surgery Flashcards

1
Q

What is one of the most common indications for laparotomies?

A

foreign body obstructions

  • DOGS = non-linear
  • CATS = linear
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2
Q

What is the holding layer of the intestines?

A

tunica submucosa

  • engage with all sutures to provide mechanical strength
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3
Q

What kind of suture is preferred for intestinal surgery? What can you do if you’re concerned about leakage? What should be done before abdominal closing?

A

small, monofilament synthetic absorbable or nonabsorbable swaged on taper needles

cover surgical site with omentum or serosal patch

lavage

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4
Q

What cleanliness level is associated with intestinal surgery? How can this be alleviated?

A

clean-contaminated or contaminated

  • replace contaminated instruments and gloves before closing abdomen
  • use prophylactic antibiotics
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5
Q

What prophylactic antibiotics are recommended for the different segments of the intestines?

A

UPPER AND MIDDLE SMALL INTESTINE - first-generation cephalosporins (cefazolin)

LOWER SMALL INTESTINE AND LARGE INTESTINES - second-generation cephalosporins (cefoxitin)

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6
Q

Why are multifilament sutures not recommended for intestinal surgery? How should tissues be handled?

A

causes more tissue drag and potentiates infection

handle gently and grasp as little as possible —> risks intestinal occlusion

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7
Q

What clinical signs are associated with intestinal foreign bodies?

A
  • vomiting
  • anorexia
  • depression
  • abdominal discomfort
  • diarrhea
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8
Q

What is seen on radiographs with intestinal foreign bodies? How is it confirmed?

A

multiple loops of gas-filled dilated intestines

compare ratio of small intestine diameter to the height of the cranial endplate of L2

  • <1.6 - no obstruction
  • > 3 - strongly associated with obstruction
  • > 4 - 95% confidence for obstruction
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9
Q

How are intestinal foreign bodies treated?

A

explore the entire abdomen for intestinal viability

  • healthy = enterotomy
  • necrotic = R/A
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10
Q

How is intestinal viability evaluated?

A
  • peristalsis on pinch test
  • color (purple = necrotic)
  • pulsation of vessels and motility
  • wall texture or thickness (thin = nonviable)
  • fluorescein infusion
  • surface oximetry
  • bleeding of sero-muscularis when incised
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11
Q

What are the 3 indications for enterotomies?

A
  1. removal of intraluminal foreign bodies
  2. full-thickness biopsy samples
  3. evaluation of intestinal mucosa to determine viability
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12
Q

What is the general surgical technique of enterotomies?

A
  • milk stool away and atrumatically occlude intestine (with Doyens) proximally and distally to prevent leakage
  • make a stab incision into the lumen and extend with scalpel or Metzenbaum scissors ABORAD to the foreign body

(if incision is too small, risk traumatizing the tissue with removal)

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13
Q

Where are intestinal foreign bodies most commonly found?

A

caudal duodenal flexure

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14
Q

How are enterotomies closed? What is avoided?

A

simple continuous or interrupted sutures 2-3 mm from the edges and each other to appose the mucosa accurately (AVOID EVERSION)

  • double layer —> makes lumen too stenotic
  • long tags
  • rough handling —> hematomas
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15
Q

How can the diameter of the intestinal lumen be increased in enterotomies?

A

close transversely by placing the suture at the center of the incision

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16
Q

How can eversion after suturing up an enterotomy be avoided?

A

thumb forceps can correct position and go under the submucosa to engage it

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17
Q

What is performed after suturing up an enterotomy or eneterectomy? What kind of test is this?

A

water test - saline injected into lamina to check for leak (leakage = more suture or omental patch)

SUBJECTIVE —> all anastomosis can be made to leak if enough pressure is applied

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18
Q

What are the 4 indications for enterectomies?

A
  1. removal of non-viable (necrotic or ischemic) instestine
  2. removal of irreducible intussusceptions
  3. removal of traumatized intestines
  4. removal of solitary neoplasms and fungal lesions
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19
Q

How is pulse oximetry and fluorescein dye used to detect intestinal viability?

A

normal saturation would be within 1 cm of normal peripheral O2 saturation

detects non-viable bowels

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20
Q

What is the standard technique for enterectomies?

A

end to end approximating pattern using simple interrupted or continuous suture

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21
Q

How are simple continuous sutures placed for enetercomies? What 3 advantages are there?

A

only 180 degrees —-> 360 not recommended

  1. technically easy
  2. maximizes luminal diameter
  3. results in rapid mucosal regeneration
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22
Q

What is the general surgical technique of enterectomies?

A
  • mesenteric vessels of the segments of the intestine to be remove are ligated
  • 2 clamps are placed on each side of the area of resection
  • intestine is transected with a scalpel or scissors

(debride fat, which makes it harder to close)

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23
Q

What clamps are used on enterectomies? How do the borders of the intestines compare?

A
  • atraumatic Doyens on conserved intestine
  • crushing clamps on the section to be removed

antimesenteric border is shorted than the mesenteric

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24
Q

How are the intestines cut on enterectomies to preserve the diameter? How is torsion avoided?

A

cut is angled

one suture on the mesenteric then antimesenteric borders for apposition, then the remaining suture are placed 3 mm from the edge of tissue and each other (keep tags long initially to manipulate intestines without touching)

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25
Q

How is the rent on the mesentery sutured?

A

with very delicate sutures to avoid stricture in the future

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26
Q

How are anastomoses between sections of intestines with disparity in lumen size done?

A
  • transect the small segment at an acute angle and a large segment at a more obtuse angle
  • space sutures in the large segment farther apart
  • incise the antimesenteric border of the smaller segment to spatulate (fish-mouth) the smaller segment
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27
Q

What are the 3 types of intestinal anastomosis? How are staples placed?

A

1 end to end
2. end to side
3. side to side

place 3 stay sutures, then apply the staples —> causes some eversion that can lead to further adhesions

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28
Q

How is the mesentery sutures following an enterectomy?

A

3-0 or 4-0 absorbable sutures in a simple continuous or interrupted pattern

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29
Q

What is an omental patch? Serosal patch?

A

the greater omentum is wrapped around a surgical site for support and to stimulate healing

taking the antimesenteric border of a healthy, adjacent intestinal loop and suturing it over a defect for support

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30
Q

What are 2 indications for serosal patching?

A
  1. questionable area of suturing after and eneterotomy or anastomosis with tension, damage to serosa, or dehiscence
  2. superficial trauma to the intestinal wall
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31
Q

How is a serosal patch attached to the intestine? What should be avoided?

A

sutures engage the submucosa, but DO NOT penetrate the mucosa

twisting, stretching, or kinking of the intestine or mesenteric vessels

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32
Q

What are 4 indications for serosal patching? When will mucosa span the defect?

A
  1. when omentum is not available
  2. closure integrity is questionable
  3. non-resectable duodenal defects
  4. enterotomy, colotomy, urinary bladder

within 8 weeks

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33
Q

What kind of anastomosis do staplers provide?

A

side to side, functional end to end

(GIA and TA staplers)

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34
Q

What is an enteroenteropexy? How is it performed?

A

intestinal plication developed to prevent recurrence of intussusception

small intestine is placed in gentle loops and seromuscular/submucosal layers are sutured with small simple interrupted sutures

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35
Q

What kind of incision is preferred for enterotmoies? Where is it placed?

A

longitudinal

on the antimesenteric border ABORAD (distal) to the obstruction

36
Q

How are enterotomies closed?

A

longitudinally with 4-0 monofilament in a simple continuous or interrupted pattern

  • sutures 2-3 mm from edge and apart
37
Q

What is the point of omentalizing?

A
  • angiogenic
  • immunogenic
  • adhesive
  • controls infection
  • lymph drainage
38
Q

How does the use of scissors and scalpels compare for cutting intestine?

A

SCISSORS = more control, more traumatic

SCALPEL = less control, less traumatic

39
Q

What kind of intestinal obstruction results in more severe signs?

A
  • complete
  • high
  • strangulated
40
Q

What are some clinical signs associated with intestinal obstruction?

A
  • vomiting
  • dehydration
  • electrolyte imbalance, acid-base abnormalities
  • abdominal pain
  • distended loops of intestine on radiographs
  • palpable abdominal mass
41
Q

How should patients be stabilized for intestinal obstructions?

A
  • correct acid-base, fluid, and electrolyte abnormalities
  • IV antibiotics with first dose at induction and every 90 mins during procedure: cefazolin (stomach, proximal intestine) and cefoxitin (lower small intestine, colon)
  • treat shock
42
Q

How should foreign bodies in the colon be corrected?

A

if they were able to pass into the colon, they usually pass in the feces

  • only remove surgically if there is concern for damage (sharp objects)
43
Q

What are the 6 most common causes of intestinal obstruction?

A
  1. foreign bodies - linear in cats, non-linear in dogs
  2. intussusception - young dogs
  3. mesenteric torsion - older GSD
  4. ileus - post-op or post-obstruction
  5. neoplasia
  6. trauma
44
Q

How sensitive if the GIT to hypoxia?

A
  • superficial villus injury after 20 mins
  • destruction of villus after 60 mins
  • wall edema, bleeding, and mucosal sloughing within 1-3 hours
  • transmucosal necrosis after 4 hours
  • turgidity, transmural infarction, and whole blood accumulation within 8 hours
  • black, distended, and elongated appearance within 8-12 hours
  • gaseous bowel distention and loss of fluid into the lumen within 12-36 hours
  • gross necrosis within 20 hrs

death due to hypovolemia within 3-4 days

45
Q

What acid-base changes are expected with intestinal obstructions at different segments?

A
  • pyloric/proximal duodenal = metabolic alkalosis
  • mid-duodenal/ileal = metabolic acidosis
46
Q

What are 3 causes of fluid loss associated with intestinal obstruction?

A
  1. vomiting
  2. sequestration in intestinal lumen due to increased secretion and decreased absorption
  3. edema of intestinal wall, especially with venous occlusion
47
Q

What is strangulating obstruction? What 4 things does this result in?

A

simple obstruction leading to occlusion of blood supply to the intestine

  1. bacterial overgrowth
  2. increased bowel permeability
  3. perforation and escape of bowel contents
  4. peritonitis
48
Q

What are 5 causes of strangulating obstructions?

A
  1. strangulated hernia
  2. some foreign body obstruction
  3. intussusception
  4. mesenteric torsion
  5. adhesions/bands
49
Q

What are the most common linear foreign bodies? How do they occur?

A

CATS —> thread, nylon stocking, rope, string

  • anchors around the base of the tongue or pylorus
  • peristalsis carries FB down the GIT to form accordion-like pleats
  • FB embeds in mesenteric border and can perforate intestines
50
Q

What are the most common clinical signs associated with linear foreign bodies?

A
  • vomiting
  • anorexia
  • depression
  • abdominal palpation results in pain and clumping/pleating of intestine
51
Q

What is avoided when removing linear foreign bodies?

A

pulling it out —> don’t know what is at the end or how far it has gone

52
Q

What is observed on radiographs and contrast studies in patients with linear foreign bodies?

A

plicated intestines bunched in the cranial/central abdomen

more obvious pleating with teardrop shaped air bubbles

53
Q

Where are linear foreign bodies most commonly lodged in dogs?

A

at the pylorus —> need surgery, 40% have peritonitis at the time of surgery

54
Q

How are linear foreign bodies surgically managed?

A
  • free FB cranially from the base of the tongue or by gastrotomy
  • examine the mesenteric border for perforations
  • remove the FB through enterotomy(ies)
55
Q

How are linear foreign bodies surgically managed with a catheter?

A
  • free FB cranially
  • make a 1 cm enterotomy in the antimesenteric border of the proximal duodenum
  • tie FB to the catheter and milk it doen the intestines
  • comes out of anus or separate enterotomy incision

(aka Andersen technique)

56
Q

How are mesenteric perforations treated in cases of foreign bodies?

A
  • examine the mesenteric border with FB in place
  • repair the perforation

(if there are multiple perforations or compromise to the blood supply, a R/A if recommended)

57
Q

Linear foreign body:

A

accordian-like plication!

58
Q

How do linear foreign bodies typically affect the intestine?

A

may lacerate the mesenteric border

  • R/A recommended if intestine is perforated
59
Q

What is intussusception?

A

telescoping of one segment of intestine (intussusceptum) into an adjacent section (insussuscipiens)

  • intussuseptum is usually proximal, but reverse peristalsis can cause reverse telescoping
60
Q

In what animals is intussusception most common? What does this commonly result in?

A

puppies —> associated with hypermotility, usually caused by diarrhea or parasites

  • venous occlusion
  • perforation
  • peritonitis
  • bloody diarrhea, vomiting, abdominal pain
    (often palpable)
61
Q

What are the characteristic signs of intussusception on ultrasounds?

A
  • dart board
  • side view = 4 layers of intestine
62
Q

How are intussusceptions surgically treated?

A

gentle traction to take back intestine

  • if going well, monitor to recognize recurrence
  • check viability, necrotic intestines require R/A
  • irreducible = R/A
63
Q

What is the most common signalment for mesenteric torsion?

A
  • medium to large breed dogs, especially GSDs and Pointers
  • adult males
64
Q

What are 9 predisposing factors to mesenteric torsion?

A
  1. vigorous activity
  2. dietary indiscretion
  3. trauma
  4. recent GI surgery
  5. enteritis
  6. parasitism
  7. FB/obstruction
  8. exocrine pancreatic deficiency
  9. GDV
65
Q

What are clinical signs of mesenteric torsion associated with? What are some examples?

A

partial obstruction and ischemia of the intestine

  • acute pain and shock
  • mild abdominal enlargement
  • depression, recumbency
  • nausea, retching, vomiting
  • hematochezia
66
Q

What surgical treatment is recommended for mesenteric torsion?

A
  • untwist and reposition intestine
  • allow for perfusion and evaluate tissue viability
  • resect devitalized tissue
  • lavage abdomen, drain the peritoneum

(must be done within 60 mins, euthanasia is commonly treatment)

67
Q

How much of the intestine is able to be resected? What happens if more is taken?

A

60-70%

short bowel syndrome - not enough bowel to absorb nutrients, resulting in weight loss, diarrhea, malnutrition, anemia (folic acid def.) —> requires special diet for life and supportive therapy until remaining intestine adapts

68
Q

Why must mesenteric torsion treatment be done especially quickly?

A
  • mortality approaches 100%
  • in most cases, entire jejunum and ileum are non-viable at the time of surgery
  • reperfusion injury can be lethal
  • short bowel syndrome
69
Q

What post-op care is recommended for intestinal surgery?

A
  • offer water or nasogastric tube trickle 6-8 hours after surgery
  • if no vomiting occurs, offer bland food 12-24 hours after surgery
  • reintroduce normal diet gradually at 48 hours after surgery
  • no antibiotics unless peritonitis is present
70
Q

What are the 4 most common causes of peritonitis and dehiscence following intestinal surgery? What does this usually lead to?

A
  1. poor suturing technique
  2. non-viable bowel
  3. use of chromic gut
  4. delated healing (Cushings)

SEPTIC PERITONITIS —> occurs between 3rd and 5th day following surgery

71
Q

What are the 2 options for peritoneal drainage to avoid peritonitis?

A
  1. open abdominal drainage with highly absorbent padding over opening
  2. close abdominal drainage with a Jackson Pratt for active drainage
72
Q

Where in the GIT is neoplasia most common in dogs and cats?

A

DOGS = colon and rectum

CATS = small intestine

(most are malignant and highly metastatic)

73
Q

What intestinal neoplasias are most common in dogs and cats?

A

DOGS = adenocarcinoma (M, intestinal), adenomatous polyp (B, rectal)

CATS = lymphosarcoma (M, intestinal)

74
Q

What is the most common signalment for intestinal adenocardinoma?

A
  • dogs = 9 years; cats = 10 years
  • dogs = males, cats = females

Boxers, Collies, GSD, Siamese cats

75
Q

How do the clinical signs differ with small and large intestinal neoplasias?

A

SMALL = weight loss, anorexia, depression, diarrhea, vomiting

LARGE = tenesmus, hematochezia, dyschezia, weight loss (more straining!)

76
Q

What is most commonly seen on physical examination in intestinal neoplasia?

A
  • palpable abdominal or rectal mass
  • dilated loops of intestine (obstruction)
  • anemia: leiomyosarcoma bleeding into intestine
  • peritonitis: perforation, necrosis
77
Q

What is seen on radiography and ultrasonography with intestinal neoplasia?

A

RADIOGRAPHY - abdominal mass, dilated intestinal loops, intramural or annular lesions, diffuse filling defects in bowel wall

US - enlarged lymph nodes, hepatic masses

78
Q

When is intestinal R/A recommended for neoplasia? When is chemotherapy recommended?

A
  • single mass
  • can resect < 70% of small intestine
  • no metastatic lesions present

lymphosarcoma has some success (adenocarcinoma has poor results)

79
Q

How is the treatment of malignant and benign neoplasia different? Prognosis?

A
  • MALIGNANT: resection with 4-8 cm borders, only resect lymphosarcoma is obstructing
  • BENIGN: resection with minimal borders

ADENOCARCINOMA: dogs = 10 months; cats = 2 years
LEIOMYOSARCOMA: 12 months

80
Q

How are surgical intestinal biopsies performed? What techniques are used?

A

full-thickness biopsy wide enough that all layers remain intact (3-4 mm wide) —> most invasive, most diagnostic

  • longitudinal biopsy with longitudinal* or transverse closure
  • transverse biopsy
  • dermal punch
81
Q

How are transverse wedge biopsies performed?

A

full-thickness wedge 3-4 mm wide taken perpendicular to long axis of intestine

(should not be > 20-25% of circumference)

82
Q

What are 4 characteristics of flexible endoscopy for biopsying the intestine?

A
  1. least invasive
  2. able to visualize mucosa
  3. jejunum out of reach
  4. no muscular layer
83
Q

What are 3 characteristics of laparoscopic-assisted biopsies?

A
  1. can biopsy jejunum and other organs
  2. full thickness
  3. cannot visualize mucosal lesions
84
Q

How are antibiotics used in intestinal surgery?

A
  • PROXIMAL SMALL INTESTINE = 1st gen, cefazolin
  • DISTAL SMALL INTESTINE = 2nd gen, cefoxitin
  • if used, should be in tissues by the time of surgery
  • continue no more than 24 hours post-surgery unless there is an ongoing infection
85
Q

Why must pain management be done carefully after intestinal surgery?

A

opioids can cause ileus —> preemptive Cisapride

86
Q

What should be monitored following intestinal surgery? Why?

A
  • general attitude
  • mucous membranes
  • abdominal palpation (pain can be because of sx!)
  • temperature
  • CBC
  • abdominocentesis of DPL
  • ultrasonography

most complications occur in the first 3-5 days

Small Animal Surgery (34 decks)

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