Intestinal Surgery Flashcards
What antibiotic is used prophylactically in intestinal surgery?
Cafazolin
- gram - and gram +
What is the wound classification for intestinal surgeries?
Clean contaminated
OR
Contaminated
Standard criteria for assessing intestinal viability?
Pink, moist, glistening
Pulsation of mesenteric vessels
Bleeding from cut surface
Peristalsis - pinch test
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)
What suture material do you use in intestine?
Monofilament, absorbable
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
What are all the possible intestinal biopsy techniques?
Longitudinal biopsy w/ longitudinal/transverse closure
Transverse biopsy
Dermal punch
Laparoscopic (minimal invasive)
Acute/severe signs Persistent vomiting Gastric secretions Electrolyte imbalance Dehydration
Is this a proximal or distal intestinal obstruction ??
Proximal — duodenum or proximal jejunum
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
What might you see on radiographs for intestinal obstruction?
Dilated intestinal loops
Placated intestinal loops
Radiopaque foreign body
Signalment and clinical signs of linear foreign bodies?
Cat> dog
Young
Vomiting
Depression
Abdominal pain - posture, gain, guarding on palpation
What do you see on radiographs with linear foreign bodies?
Plication of intestines
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)
Complications of linear body removal?
Impaired intestinal fxn secondary to inflammatory changes
Short bowel syndrome with extensive resections
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
You do an ultrasound in a dog and see what looks like a target. What is this lesions?
Intussusception
T/F: colonoscopy can be used to visualize jejuno-jejunal and ileocolic intussusception
False
Can only visualize ileocolic
Signalment of intussusception?
Young puppies
How can you surgically manage intussusception ?
Exploratory celiotomy
Manual reduction
Resection and anastomosis (if reduction is unsuccessful or nonviable tissue)
Biopsy
You manual reduce an intussusception, but see a full thickness tear.. how will you address this?
Resection and anastomosis of tissue
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
Clinical signs associated with cecal inversion?
Chronic diarrhea with hematochezia
How can you diagnose a cecal inversion?
Radiographs - survey and contrast studies
Endoscopy
US
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%
