Laparotomy/Celiotomy Flashcards
Exploratory laparotomy/celiotomy indications
- Exploration (diagnostic), surgical correction, or procedural (e.g. C-section)
Standard approaches for exploratory laparotomy/celiotomy
- Paralumbar fossa
- Midline
- Paracostal
- Alternative approaches
How tightly should you suture up a cow for surgery?
- VERY TIGHT
- You do not want it to be loose
Casting cows
- can do with a double half hitch
Typical recumbency for sheep abdominal surgery
- Dorsal recumbency
Left paralumbar fossa approach indications
- Left side general exploration
- Traumatic reticuloperitonitis
- Vagal indigestion, rumenotomy
- LDA via abomasopexy
- Cesarean section
Right paralumbar fossa approach indications
- SI and LI access
- Correct LDA by omentopexy
- Correct RDA/abomasal volvulus
- Cesarean section
- Nephrectomy
Right paramedian approach
- correct LDA, RDA, RAV
Right paracostal approach
- Pyloric or abomasal visualization
Ventral midline approach
- Cesarean section
- Alternate approach for hardware lesion or reticular abscess
Ventrolateral approach indications
- Cesarian section for emphysematous fetus
- Repair of postpartum uterine tear
Why does Dr. Barrington prefer the left sided approach for C-section?
- No need to go in on any side other than the left side on a bovine
- if you go in on the right side, things can follow them
Landmarks for incision for Paralumbar approach
- Midway between 13th rib and tuber coxae
- Can go vertically or obliquely depending on anatomy
- Start about 2” below the transverse processes
- Extend incision about 5-6” vertically through skin and cutaneous trunci
General paralumbar fossa approach restraint
- Chute or stocks
General paralumbar approach preparation of surgical area
- Clip with 40 blade
- Surgical scrub and final surgical prep
Paravertebral block - what nerves are you blocking?
- Dorsal and ventral branches of spinal nerves from T13, L1, L2
What are advantages of the paravertebral block vs an inverted L or line block?***
- (Distal) paravertebral block you can block the peritoneum
- Line blocks it is almost impossible to block the peritoneum
- Also you have less lidocaine in your incision
Where do you block T13, L1, and L2 for the distal paravertebral block?
- T13: Transverse process of L1
- L1: Transverse process of L2
- L2: Transverse process of L4
- Palpate the transverse process and put a needle above and below
C-section overview
- If you’re reaching in and finding the greater curvature of the horn of the uterus but cannot pick up the calf
- Would have to make an incision in the uterus
- You can use a letter opener with a guarded blade to put through
- You will spill amniotic fluid into the abdomen, which isn’t that much of a problem
- Want to make you incision at the end of the uterine horn and on the greater curvature of the horn, somewhere down towards the end of the horn
- Difference between right horn and left horn presentation
- Want to get the chain around the back legs
Post-op risks after C-section
- LDA in the first week
Uterine closure and placenta exposure
- You do not want any placenta protruding - has t obe a perfect closure
- Uterus wall will contract quickly, and the placenta will come out and lead to peritonitis
- Either do one perfect incision or do two oversewn.
General approach to paralumbar fossa approach
- Skin incision
- Muscles incision (grid or not)
- Abdominal visualization on left or right side
Which muscles do you encounter when doing a paralumbar fossa approach?
- Cutaneous trunci
- External abdominal oblique
- Internal abdominal oblique
- Transverse abdominus
- Peritoneum
Gridding vs sharp dissection for paralumbar fossa approach
- Surgeon’s choice
- He likes to do a sharp dissection through the skin and the external abdominal oblique (both have a sheath that can be sewn back together)
- Internal abdominal oblique and transverse abdominus don’t have a sheath, so he pokes a hole all the way through the muscle belly and widens it
Viscera on the left side
- Rumen
- Spleen
- Bladder (very caudal)
Viscera on the right side
- Descending duodenum
- Omentum
- Right kidney
- Cecum
- Spiral colon (difficult to access)
- Jejunum and ileum
- Abomasum
- Omasum
- Liver
Exploration of the abdominal cavity in a standing paralumbar fossa approach
- Know that there are certain things that can’t be exteriorized and things that cannot be palpated
- Most of the jejunum can be exteriorized
- Ascending duodenum you can’t really pull out
What are the three T’s of successful surgery?
- Time
- Trash
- Trauma
Closure suture type for paralumbar fossa approach?
- Catgut or Braunamid 0 to #3
Layers for Paralumbar fossa approach closure
- Simple continuous pattern for non-skin layers generally
- Usually three deep layers closed (transverse abdominus and peritoneum, internal oblique, external oblique)
- Skin (ford interlocking pattern; terminal simple interrupted suture)
LDA overview
- Usually to the right of midline
- Propagated by shifts in abdominal content
- Comes up on the left
- Less likely to twist on itself due to the way it is attached
- Much more common
RDA overview
- Much less common
- May result in an RDA and/or torsion of the abomasum (torsion would result in a twisting of the mesenteric root and vasculature)
- Can lead to vascular impairment and poor prognosis
What ways do RAVs tend to twist?
- Right and to the rear
- Counterclockwise from the right and the rear
- Important so that you can untwist them the right way
What can you not pull out?
- Transverse colon
- Ascending duodenum
What else is important with a displaced abomasum surgery?
- Always perform a thorough exploration of the abdominal cavity as a high percentage of displacement have other or underlying pathology
Culling a DA
- Don’t do anything
- Don’t make a lot of money and don’t correct a lot of things
- He does not suggest
Rolling
- LDA only
- 50% success
- risk of RDA or RAV
- Doesn’t work very long
Rolling with a toggle
- LDA only
- 80% success rate with an experienced
- Putting the trochar on the right side
Steps for roll and toggle
- +/- Tranquilize and sedate
- Cast them onto the right side and roll onto back
- Clip and scrub
- Area of the loudest ping
- 4-7 inches behind the xiphoid
- Assistant places pressure on lower abdominal quadriant
- Trocharize the abdomen 4-7 inches behind xiphoid and 3 inches right of midline
- Remove handle and push rod from trochar
- Place toggle suture and push through cannula, remove trochar
- Trocharize 2nd site 2-3 inches proximally
- Tie two toggle sutures ends together, leaving space between skin and the knots
Advantage of Roll & Toggle
- Simple, quick, inexpensive
- Minimally invasive
- High success rate (>60-80%) similar to surgery
Disadvantage of roll & toggle
- Blind technique - cannot see abomasum
- Dorsal recumbent position
2 step laparoscopy what procedures for?
- LDA
- You can do it standing or not
Right paramedian approach recumbency
- Dorsal recumbency
Advantage of right paramedian
- DA usually corrects itself while cow being placed
Disadvantage of right paramedian approach
- Getting cow into dorsal recumbency and a ventral surgical site
- Okay if you have a crew
Preparation for right paramedian
- Sedate, table, or cast into dorsal recumbency
- Prepare right paramedian site
Anesthesia for right paramedian approach
- Anesthesia: line block, full thickness, lateral to incision
Entering the abdominal cavity from right paramedian approach
- Incise skin
- Rectus sheaths and muscle belly
- Want to make a big cut
Procedure for correcting LDA from right paramedian approach
- Explore abdomen, correct abomasal displacement if needed
Closure for right paramedian approach
- Abomasopexy (gastropexy) - abomasum to internal layers of body wall
- Close rectus rectus abdominus sheaths
- Skin closure
Where can you attach the abomasopexy/gastropexy?
- Attach to the transverse abdominus and peritoneum
- OR the internal rectus sheath
Left flank paralumbar fossa abomasopexy what for?
- For an LDA
- or C-section
Left flank paralumbar fossa approach recumbency
- standing
Do you always get direct visualization with the Left flank paralumbar fossa approach?
+/-
- Can see the abomasum about 30%
Disadvantage of Left flank paralumbar fossa approach
- Pexy requires reaching under the ventral sac of the rumen to the right paramedian area (arm length)
- Limited exploration
Description of Left flank paralumbar fossa approach
- Standard left flank anesthesia and surgical approach
- Limited exploration of abdomen
- 4-6” continuous bites are placed in greater curvature of abomasum, 2-3” off greater omentum attachment (often blind). Make sure you leave long tails
- Suture is placed to leave 1+ meter tails
- Decompress the abomasum
- Cranial end: ~10 cm caudal to xiphoid, right of midline (pass needle through body wall
- Caudal end: ~10 cm caudal to cranial end
- Surgeon pushes deflated abomasum ventrally as assistant pull sutures bringing abomasum to ventral abdominal wall
- Sutures tied together externally, fixing abomasum in position
Post-op care for left flank abomasopexy
- Tie a knot and leave it there for two weeks
Advantages of left flank abomasopexy
- Abomasal adhesions are best broken down by this approach
- can also address problems involving the rumen
- Fewer people needed
- Standing procedure
Left flank abomasopexy disadvantages
- Short people + big cow makes flank incision lower
- Viscera puncture a risk
- Exposure of abomasum sometimes difficult
Right flank/paralumbar fossa omentopexy what for?*
- LDA, RDA, RAV
Approach for right flank/paralumbar fossa omentopexy
- Standard abdominal approach
- Standing
Success rate of right flank/paralumbar fossa omentopexy
- Redisplacements are slightly more common with this approach
- Omental stretching or tearing
LDA procedure for right flank/paralumbar fossa omentopexy
- Decompress with a needle attached to tubing (simplex)
- Have to reach over the top of the rumen
- Retract to the right side
RDA or RAV procedure for right flank/paralumbar fossa omentopexy
- Easy to find
- Decompress and replace to proper position
What appearance does the pylorus have?
- “Sow’s ear”
Omentopexy in right flank/paralumbar fossa omentopexy
- Incorporate omentum adjacent to pylorus into closure of peritoneum and transverse abdominus
- Pyloropexy done by some, but be careful
Closing right flank/paralumbar fossa omentopexy
- Tension suture to bring it together into the closure
- Omentum into peritoneum
- Close the internal abdominal oblique separately
- Still a risk of RDA
Pre-op medications for LDA/RDA
- Flunixin meglumine
- +/- antibiotics
Post-op medications for LDA/RDA
- Drench with electrolytes (post)
- Support rumen - get cow back on feed
- Monitor site
- Observe drug withdrawal
