Intestinal surgery

Question 1

Negative effect on intestine healing

Answer 1

Etiology of obstruction (FB have more leakages)
Failure to ID ischemic tissue
Improper suture and staple
Sepsis- mortality up to 70%
Malnutrition
Antineoplastic

Question 2

Positive effects on early eating

Answer 2

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.

Question 3

Mechanical ileus

Answer 3

Physical luminal obstruction. 
Simple: complete v Partial
Strangulating
Ischemia and devitalization- decreases fluid absorption
Bowel wall edema

Question 4

High v low obstruction

Answer 4

> 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.

Question 5

Obstructive pattern

Answer 5

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

Question 6

Ultrasonography

Answer 6

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

Question 7

Intestinal biopsy

Answer 7

Indications: inflammatory bowel disease, neoplasia, fungal granuloma, intestinal parasitism
MAKE THE DIAGNOSIS

Question 8

Biopsy techniques

Answer 8

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

Question 9

Enterotomy

Answer 9

Less risk of surgical dihiscense. Retain and absorptive capacity.
Disadvantage: wrong guess- perforation+ peritonitis

Question 10

Enterotomy closure

Answer 10

Simple interrupted. Simple cutaneous. Cushing or Connell. Stapled.
Leak Test
OMENTAL WRAP

Question 11

Cushing

Answer 11

Potentially a good choice for malnourished or preexisting sepsis. Narrows lumen diameter!!!!!!

Question 12

Canine linear foreign bodies

Answer 12

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.

Question 13

Strangulating obstruction

Answer 13

Impaired venous drainage- arterial blood supply intact, ischemia
Necrosis foreign body
Mesenteric vascular disruption (trauma)
Local pressure volvulus: intussusception, hernia thromboembolism

Question 14

Intestinal viability

Answer 14

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

Question 15

Short bowel syndrome

Answer 15

Remaining bowel gets larger in diameter with thick mucosa to increase absorption
Don’t remove duodenum- chronic diarrhea because closely attached to the pancreas

Question 16

End to end anastomosis

Answer 16

Luminal disparity. Antimesenteric incision. Most leaks occur at the mesenteric border.

Question 17

Inversion of wound

Answer 17

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.

Question 18

Eversion of the wound

Answer 18

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.

Question 19

Crushing vs Approximating

Answer 19

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?

Question 20

Modified Gambee

Answer 20

Just an approximating pattern where you attempt to exclude the mucosa with the tip of the needle.

Question 21

Pressure leak

Answer 21

All will leak with enough force. 
10cm apart doyens or fingers. 
10mL water
Creates 30-40 mmHg of pressure.
3-4x physiological pressure

Question 22

Bursting strength

Answer 22

Day 1: Inverting> approximating> everting
Day 2: approx> invert> evert
Day 14: Approx>invert>evert

Question 23

Septic Abdomen

Answer 23

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

Question 24

Monofilament non-absorbable

Answer 24

Minimal reaction. Don’t use continuous pattern- impedes distention.
May cause delayed intestinal obstruction due to adherence of foreign material

Question 25

Absorbable monofilament

Answer 25

Non-adherence of bacteria. 
Plus- impregnated with tryclosan. 
Highly variable absorption times
Suture of choice. 
Ration for use of rapidly absorbed monofilaments wanted (cystotomy closure because that totally relates to this lecture)

Question 26

Braided synthetic absorbables

Answer 26

Bacterial adherence. European and human docs use commonly. Studies lacking. Not recommended.

Question 27

Staples

Answer 27

Faster. Approximate healing with slight eversion. Similar bursting strengths.

Question 28

Intestinal volvulus

Answer 28

German shepard- EPI
Jejunum twists on mysentery. 
Peracute collapse and vomiting. Dilated loops of bowl. Fluid in the abdomen. 
Grave >95% mortality rate. 
Survivors: short bowel syndrome. 
Must retain >20% of the intestines.

Question 29

Neoplasia

Answer 29

Lymphoma and adenocarcinoma- partial obstruction.

GMS stain for hyphae.