Laparotomy Flashcards
What are the 3 major indications for laparotomies/celiotomies?
- investigation to establish/confirm diagnosis, determine extent of disease or establish a prognosis
- surgical correction of disease
- supportive or prophylactic procedures
What are 4 major indications for emergent celiotomy?
- uncontrollable hemorrhage or inability to stabilize patient
- free air on radiographs indicative of a perforated bowel
- penetrating abdominal injury
- bacteria, plant material, bilirubin, or predominantly toxic neutrophils on cytology
What approach is used for exploratory celiotomies? What is required for adequate exposure?
systematic inspection (visual and palpation) of all contents - top to bottom vs. organ systems
incision from xyphoid to umbilicus or pubis to optimize visualization
How are patients prepared for exploratory celiotomies?
- clip wide and drape narrow to allow ability to extend incisions and maintain minimal cutaneous exposure
- 4 quarter draping
- dorsal recumbency
- aseptic scrubbing
How do surgeons prepare for exploratory celiotomies?
- count (radiopaque) sponges, sharps, and instruments (repeat count if sponges are added)
- place the ground plate of cautery devices ahead of time, since it’s hard to do once draped without breaking sterility
What is the most common surgical approach to laparotomies?
ventral midline
What is the paramedian approach? What is the most common reason this is done? Why is it mostly avoided?
an incision parallel to and just off of midline
usually caused by a missed ventral midline incision
cuts into muscle
What is the paracostal approach?
incision parallel to the last rib along the internal/external obliques and transversus
What is the flank approach? Why is it avoided?
incision perpendicular to the ventral midline, can be used to spay cats
results in a blood incision
What are 2 common combinations of surgical approaches to laparotomies? Why are they used?
- ventral midline and paracostal - liver approach
- ventral midline and median sternotomy - dogs with chronic diaphragmatic hernias with adhesion
What combination approach to laparotomies are used in males?
ventral midline and parapreputial
How does the linea alba of cats compare to dogs?
CATS = wider, more transparent
DOGS = may need to dissect away subcutaneous tissue to visualize it better
excessive dissection may result in dead space
What is the general approach to opening up for an exploratory?
- ventral midline approach
- stab incision created at 45 degrees
- extended cranially if using a scalpel and groove director or caudally if using scissors
- palpation with finger after slightly opened with blunt dissection of adhesions
- xyphoid to umbilicus/pubis
Where is the falciform ligament found? What is done to it in exploratory celiotomies?
starts at umbilicus and goes cranial to the end of the abdominal cavity
resected from umbilicus cranially if it is really big, since it can form adhesions
What organs are found in the cranial abdomen?
- diaphragm
- esophageal hiatus
- liver
- gall bladder
- stomach
- left limb of the pancreas
What organs are found in the central abdomen?
- ascending colon
- ileum
- jejunum
- mesenteric nodes
What organs are found in the caudal abdomen?
- duodenocolic ligament
- urinary bladder
- uterine body
- prostate
What organs are found in the right abdomen?
- duodenum
- right limb of the pancreas
- right adrenal gland
- right ureter
- right kidney
- right ovary and uterine horn
What organs are found in the left abdomen?
- descending colon
- spleen
- left kidney
- left adrenal
- left ovary/uterine horn
- left ureter
What must be done before closure of exploratory celiotomies?
- check biopsy sites for hemorrhage
- sponge count
- lavage with warm irrigation system
What is the point of lavaging before closing exploratory celiotomies?
- dilutes contaminated surgery sites, perforated bowels, and peritonitis
- can warm hypothermic patients
(minimum 200-300 mL/kg
How are exploratory celiotomies closed?
3 layer closure
- external rectus fascia (holding layer) - simple interrupted or continuous
- subcutaneous tissue - simple interrupted or continuous
- skin - intradermal or external sutures
What 2 types of suture are preferred for the external rectus sheath? What are the recommended suture sizes?
- intermediate to long-lasting absorbable - PDS, PGS
- nonabsorbable if delayed healing is expected - polypropylene, monofilament nylon
- < 5 kg = 3-0
- 5-10 kg = 2-0
- > 10 kg = 0
How are bites spaced when closing the fascia?
at least 5 mm wide —> close enough to appose tissue with no gaps, should not be able to insert tips of hemostats between sutures
- do NOT incorporate muscle
How is closing the external rectus sheath of paramedian incisions different? Why?
closure of the internal rectus sheath is NOT necessary
- promotes adhesions
- most potent trigger for hypoxia
How can closure of the external rectus sheath be evaluated?
- lift on suture bites, whole body wall should move
- place finger in incision line and lift up, trying to insert tips of hemostats between sutures
(bites < 5 mm wide have half the strength of those > 5 mm wide)
What is the most common pattern for closing subcutaneous tissue? Why? How can dead space be decreased?
simple continuous - has increased bursting strength and distributes force equally
interrupted sutures with bites into underlying fascia
(ensure vertical bites enter and exit close to the base of the dermic for best apposition)
What is the intradermal suture pattern?
- continuous patter where bites are taken parallel to the wound edge at the base of the dermis
- suture bites exit and enter directly across from each other or slightly overlap for tighter closure
How do subcutaneous and intradermal compare?
SQ = better for animals with a lot of subcutaneous fat, bites taken perpendicular to skin edge
INTRADERMAL = used for more accurate apposition, skin sutures may not be necessary, bites taken parallel to skin edge
What is the point of burying the knot? In what 2 patterns is this done?
inverted knots reduce likelihood suture ends will become exposed
- subcutaneous
- intradermal
How is burying the knot done?
- first bite = deep to superficial
- second bite = superficial to deep
How far apart are skin sutures placed? What is the general rule of thumb?
~ 5 mm wide —> smaller suture = more inflammation
skin edges will appose better and with fewer sutures when wide bites are used (only suture the skin!)
What is the most common complication associated with laparotomies? What is the main cause?
evisceration
weakness in body wall closure - NOT from patients pulling out skin sutures
