Intestinal surgery Flashcards
Negative effect on intestine healing
Etiology of obstruction (FB have more leakages) Failure to ID ischemic tissue Improper suture and staple Sepsis- mortality up to 70% Malnutrition Antineoplastic
Positive effects on early eating
Reduces muscle atrophy
Decreases incidence of ileus
Reduces incidence of transmural bacterial migration through bowel wall
High protein meals increase get levels of actin, myosin, collagen, elastin.
Mechanical ileus
Physical luminal obstruction. Simple: complete v Partial Strangulating Ischemia and devitalization- decreases fluid absorption Bowel wall edema
High v low obstruction
> 50% secrections of stomach duodenum, proximal jejunum.
Most resorbed in jejunum and ileum.
Duodenal obstruction- loss of salivary, gastric, pancreatic, duodenal secretions, >rapid dehydration.
Low jejunal obstruction- resorptive capacity maintained- chronic signs.
Obstructive pattern
Dog: Maximal small intestinal diameter- >1.6x the height of the body L5 measured at the mid centrum.
>2x have 80% chance of obstruction
Cat: Maximal small intestinal diameter should not exceed 12 mm
Distended 4x rib or 1.6x height of 5th lumbar vertebra
Ultrasonography
Normal: visualize 5 layers of alternating echogenicity
Indirect diagnosis: dilated, fluid dilled small intestinal loops
Non-linear foreign body: variable hyperechoic curvilinear line with distal acoustic shadowing
Neoplasia- mass/wall thickening
Lack of visualization of normal wall layers
Intestinal biopsy
Indications: inflammatory bowel disease, neoplasia, fungal granuloma, intestinal parasitism
MAKE THE DIAGNOSIS
Biopsy techniques
Longitudinal incision with longitudinal closure- no tension, smaller luminal diameter.
Longitudinal with transverse closure- maintains luminal diameter, more tension on suture line than with other techniques. NO.
Transverse incision with transverse closure.
Baker punch tech
Enterotomy
Less risk of surgical dihiscense. Retain and absorptive capacity.
Disadvantage: wrong guess- perforation+ peritonitis
Enterotomy closure
Simple interrupted. Simple cutaneous. Cushing or Connell. Stapled.
Leak Test
OMENTAL WRAP
Cushing
Potentially a good choice for malnourished or preexisting sepsis. Narrows lumen diameter!!!!!!
Canine linear foreign bodies
67% originate in the pylorus.
20-25% mortality- 50% perforated and increases with the amount of enterotomy sites
Surgery:
Multiple enterotomies: less complicated but increased mortality.
Single enterotomy utilizing red rubber: decreased mortality, but potentially devitalize more intestines.
Enterectomy risk short bowel syndrome.
Strangulating obstruction
Impaired venous drainage- arterial blood supply intact, ischemia
Necrosis foreign body
Mesenteric vascular disruption (trauma)
Local pressure volvulus: intussusception, hernia thromboembolism
Intestinal viability
Decompress the bowel
Color, arterial pulsations, and peristalsis pinch test
Experimental: intravenous vital dyes. Surface oximetry (>82% saturation)
NO MORE THAN 80% OF SMALL INTESTINE CAN BE REMOVED
Short bowel syndrome
Remaining bowel gets larger in diameter with thick mucosa to increase absorption
Don’t remove duodenum- chronic diarrhea because closely attached to the pancreas
End to end anastomosis
Luminal disparity. Antimesenteric incision. Most leaks occur at the mesenteric border.
Inversion of wound
Reduces lumen diameter.
Rapid serosal heal, food early bursting strength. Mucosal edema and necrosis. Internal cuff sloughs. Single layer as strong as double layer. Use in colon. More strictures.
Eversion of the wound
Horizontal mattress. A simple interrupted approximating pattern in the small intestine often allows for mucosal eversion between sutures.
Delayed fibrin seal. Delayed mucosal regeneration. Mucocele formation. Prolonged inflammatory phase response. Marked adhesion formation. Eversion in the face of sepsis often allows for dehiscence and leakage.
Crushing vs Approximating
Approximation: primary intestinal healing. Rapid regen of mucosa. Rapid revascular of submucosa. Reduced adhesion formation. Best bursting strength after 24 hours.
Crushing: Don’t do it?
Modified Gambee
Just an approximating pattern where you attempt to exclude the mucosa with the tip of the needle.
Pressure leak
All will leak with enough force. 10cm apart doyens or fingers. 10mL water Creates 30-40 mmHg of pressure. 3-4x physiological pressure
Bursting strength
Day 1: Inverting> approximating> everting
Day 2: approx> invert> evert
Day 14: Approx>invert>evert
Septic Abdomen
Reduces effect of omentum. Increases collagenase at the wound site. Protein loss and loss of glucose. Increases leakage rate from 14 to 75% in dogs and 5 to 50% cats
Monofilament non-absorbable
Minimal reaction. Don’t use continuous pattern- impedes distention.
May cause delayed intestinal obstruction due to adherence of foreign material
