Intestinal Surgery Flashcards by Corinne Perra

What antibiotic is used prophylactically in intestinal surgery?

Cafazolin

gram - and gram +

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What is the wound classification for intestinal surgeries?

Clean contaminated
OR
Contaminated

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Standard criteria for assessing intestinal viability?

Pink, moist, glistening
Pulsation of mesenteric vessels
Bleeding from cut surface
Peristalsis - pinch test

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What technique is used for suturing the intestine?

Appositional pattern - recommended for primary healing (simple interrupted or simple continuous)

Modified Gamble - to help with everted mucosa
— sutures must penetrate the submucosa (holding layer)

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What suture material do you use in intestine?

Monofilament, absorbable

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How is a transverse wedge biopsy done?

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

Wedge should not be > 20-25% of circumference

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What are all the possible intestinal biopsy techniques?

Longitudinal biopsy w/ longitudinal/transverse closure

Transverse biopsy

Dermal punch

Laparoscopic (minimal invasive)

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Acute/severe signs
Persistent vomiting 
Gastric secretions 
Electrolyte imbalance 
Dehydration

Is this a proximal or distal intestinal obstruction ??

Proximal — duodenum or proximal jejunum

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Intermittent anorexia
Occasional vomiting
Can occur over several days/weeks

Is this a proximal or distal intestinal obstruction?

Distal - distal jejunum, ileum, or ileocecal junction

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What might you see on radiographs for intestinal obstruction?

Dilated intestinal loops
Placated intestinal loops
Radiopaque foreign body

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Signalment and clinical signs of linear foreign bodies?

Cat> dog
Young

Vomiting
Depression
Abdominal pain - posture, gain, guarding on palpation

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What do you see on radiographs with linear foreign bodies?

Plication of intestines

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How do you manage a linear foreign body?

Free FB cranial by removing from base of tongue or performing gastrotomy

Examine mesenteric border of intestine for perforations

Remove foreign body through gastrotomy and enterotomy(ies)
—> remove pieces at a time, no tension (tears mucosa)

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Complications of linear body removal?

Impaired intestinal fxn secondary to inflammatory changes

Short bowel syndrome with extensive resections

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How would you remove a non-linear foreign body?

Complete abdominal exploratory

Removal through enterotomy aboral to FB on anti-mesenteric side

Resection and anastomosis if non-viable

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You do an ultrasound in a dog and see what looks like a target. What is this lesions?

Intussusception

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T/F: colonoscopy can be used to visualize jejuno-jejunal and ileocolic intussusception

False

Can only visualize ileocolic

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Signalment of intussusception?

Young puppies

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How can you surgically manage intussusception ?

Exploratory celiotomy

Manual reduction

Resection and anastomosis (if reduction is unsuccessful or nonviable tissue)

Biopsy

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You manual reduce an intussusception, but see a full thickness tear.. how will you address this?

Resection and anastomosis of tissue

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What is enteroplication? What are the complications?

Plication of the entire small intestine..
avoid tight turns

An attempt to prevent recurrence of intussusception

Obstruction, strangulation, perforation

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Clinical signs associated with cecal inversion?

Chronic diarrhea with hematochezia

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How can you diagnose a cecal inversion?

Radiographs - survey and contrast studies

Endoscopy

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Treatment for cecal inversion?

Attempt manual reduction
Expose through colostomy if irreducible

Typhlectomy

What breed of dog is mesenteric volvulus most common?

German shepherd

Clinical signs associated with mesenteric volvulus

Acute abdominal distention and pain Vomiting Shock Non responsive to orgogastric intubation

How does de-rotation differ between a segmental intestinal torsion vs mesenteric volvulus?

Segmental — do NOT untwist, just resection and anastomosis (better prognosis) Mesenteric volvulus — must de-rotate (risk of reperfusion injury)

How can you minimize contamination during intestinal surgery?

Pack-off affected area Separate instruments used for intestinal procedures from the rest of the pack Occlude intestine proximal and distal with intestinal forceps or fingers (unless intestine is empty) Decompress dilated bowel

What is the method followed during intestinal resection and anastomosis?

Pack off affected segment Determine extent of excision and ligate blood supply Occlude proximal and distal segments as atraumatically as possible Minimize mucosal eversion Begin anastomosis at mesenteric border Interrupted or continuous suture pattern (ligate between two sutures Close rent in mesentery Wrap anastomosis with omentum

How can you put two different sized lumens of intestine together with anastomosis?

Angle cut - enlarged lament Antimesenteric incision “fishmouth” or cheattle incision Placing mesenteric and anti-mesenteric sutures stretches the smaller segment - sutures are placed closer on the smaller segment

How can you minimize mucosal eversion in anastomosis of intestine?

Modified gambee | Can cut mucosa

When suturing two loops of intestine together. Where do you start?

Mesenteric border - leakage most common at this site (no serosa and fat in mesentery impairs visualization) Antimesenteric border

What suture patterns do you use in intestinal anastomosis?

Simple interrupted or simple continuous | 3-4mm bites

How do you leak test anastomosis?

Occlude intestine proximal and distally Inject saline until saline is evenly distended Gently compress and look for leaks

T/F: staples can be used in intestinal anastomosis ?

True — skin staples that close tightly

After leak testing your anastomosis site, what do you do before you close the abdomen?

Lavage Change gloves and instruments before closure Wrap anatamosis with omentum —> vascular and lymphatic supply improve healing

What is a serosal patch and when is it used?

Suturing of intestinal anastomosis site to colon —> reinforce suture lines in questionable tissue Omentum not available Induced permanent adhesion much stronger than omentum

Is healing of the small or large intestine faster??

Small intestine faster than large intestine —> lg initially takes 3-4weeks lag period before strengthening —> collagenolysis —> wound strength 75% of normal at 4 months

What are indications for colostomy?

Foreign body Impacted feces Biopsy

How do you close a colotomy?

Longitudinal | Single layer, simple interrupted, appositional

What are the indications for colopexy?

Recurrent rectal prolapse

Complications from colopexy?

Infection Dehiscence Recurrence

Indication for colonic resection and anastomosis ?

Megacolon Perforation Neoplasia Irreducible/necrotic intussusception

T/f: Megacolon is more common in dogs than cats

False Cats> dogs

What are causes of megacolon?

Congenital vs acquired Mechanical or functional colonic obstruction Neurologic Idiopathic (most common in cat)

Prolonged colonic distention leads to damage of??

Smooth msucle and nerve

What neurological conditions can lead to megacolon?

Lumbrosacral disease Key-Gaskell (feline progressive dysautonomia) Sacral spinal cord deformity (Manx)

What type of trauma can lead to a megacolon?

Callus formation from healing pelvic fracture and SI luxation

How would you you treat a megacolon associated with pelvic trauma?

Pelvic osteotomy — good prognosis if early (<6months)

How do you treat a megacolon caused obstructive/entrapment due to adhesion formation for OVH?

Surgical dissection and removal Potential for resection and anastomosis

Cats can get an idiopathic/primary megacolon.. what are the medical management ?

Diet -low residue diets Hydration Nama Prokinetic drug - cisapride Stool softeners - lactulose

What is the surgical management for primary megacolon in cats?

Colectomy - colocolonic anastomosis - ileocolic anastomosis - jujunocolic anastomosis Ileocecal valve preservation - bacterial overgrowth prevented - increases tension at anastomosis

T/F: prior to surgery you should use a stool softener and enema to clear the colon

False You are only going to surgery if medical management has failed.. Do NOT use these —> increased contaminated surgery

What can you expect to see in patients post op colectomy?

+/- tenesmus - 7 days Diarrhea Increased frequency of defection

How should colectomy patients be managed postop?

Taper fluid and electrolyte therapy as oral intake returns to normal Offer food and water the day after surgery unless contraindicated Pain management

Most complications due to colectomy occur in the first 3-5days post op... what will you be monitoring in these patients?

``` General attitude Mucous membranes Abdominal palpation. Temp bid to tid CBC Abdominocentesis or diagnostic peritoneal lavage (DPL) Ultrasonography Re-exploration ```

Common complications following intestinal surgery?

``` Ileus Adhesions Obstruction (intussusception, entrapment, stenosis) Dehiscence Peritonitis Short bowel syndrome ```

What are risk factors for dehiscence after intestinal surgery?

Foreign body/ trauma Perioperative albumin <2.5g/dL Postoperative rise in band neutrophils Perioperative peritonitis

What is the prognosis for intestinal surgery?

No dehiscence —> good prognosis Dehiscence (7-15% of cases) —> poor, mortality 74-85%