Lecture 15 2/14/25 Flashcards
What are the general principles of GI surgery?
-fast when feasible
-use prophylactic antibiotics
-isolate viscera
-leak test sites
-omentalize
-change gloves and instruments before closing
-pre-plan feeding tubes
-feed when awake, upright, and hungry
What are the characteristics of gastric emptying in a healthy dog?
the stomach should be relatively empty within 3 to 4 hours of a half-sized meal of a canned GI diet (low fiber, low fat, moderate protein)
What are the characteristics of preoperative preparation?
-be aware that GI problems will delay gastric emptying; may need to plan for more fasting time
-enemas should be avoided the day of surgery for rectal and colonic surgery
-temporary anal purse string suture can help contain solid food and diarrhea during surgery
What are the characteristics of prophylactic antibiotics?
-given 30-60 minutes before the incision is made
-cefazolin is most commonly used; can do IV, IM + IV, or SQ administration
-antibiotics should not be given in hypotensive patients
-MIC varies with organisms
What are the characteristics of intestinal incision closure?
-want to use a 3-0 or 4-0 absorbable monofilament on a taper needle
-need suture to maintain strength for 10 to 17 days
-want to use a gambee or appositional pattern
-want to trim or invert mucosa
-continuous or interrupted patterns can be used; interrupted is best if tissue is unhealthy
-bites should be 2-3 mm apart and 2-4 mm from incision edge
What are the characteristics of leak testing?
-typically involves injecting saline into an occluded segment in a way that mimics physiologic pressure
-can leak test with air
-can use mosquito hemostats to probe for gaps
-dehiscence was not noted in anastomoses positive leak tests when additional sutures were placed
-dehiscence was noted in some cases with negative leak tests
What are the benefits of omentalization?
-seals wound edge
-restores blood supply
-facilitates lymphatic drainage
Why should a 360 degree wrap of omentum not be placed?
can result in obstruction
What are other options besides omentalization?
-serosal patch
-transversus abdominus muscle
What are the steps of a gastrotomy?
-have suction ready
-count sponges and have separate instruments set aside for closure
-isolate stomach with moist lap pads
-place full thickness stay sutures to help hold stomach out of abdomen and reduce spillage
-make full thickness incision midway between the greater and lesser curvatures in the least vascular area
-close the mucosa with a simple continuous pattern
-close the outer three layers with an inverting pattern; invert the tissue with needle holder as you tighten each bite
What should be done whenever possible when making intestinal incisions?
-make an antimesenteric incision
-make the incision in healthy intestine; downstream is ideal but not always realistic
-leak test closures
What are the options for intestinal biopsy?
-punch
-wedge
-incisional edge harvest
What are the best practices when taking an intestinal biopsy?
-minimize sample handling
-do an appositional closure with simple interrupted, interrupted gambee, or continuous gambee closure
-omentalize to reduce risk of leakage
What is important to note about closing enterotomy sites along the long axis of the intestine?
it results in a narrowed lumen
What are the steps of a punch biopsy?
-insert punch full thickness of the antimesenteric surface
-be careful not to go through to the other side of the intestine; can do a lateral punch or place stay sutures to prevent this
-tilt instrument before removal to extract tissue sample
Why is it important to note that muosa everts of an enterotomy site?
-it will obstruct view of remaining layers
-it will need to be removed or inverted so the other layers can be properly closed
What are the steps of transverse enterotomy closure?
-place first suture in the center while inverting muosa
-place additional sutures; can be full thickness
-tack omentum over the site
-leak test the closure
What are the steps of an intestinal resection?
-place atraumatic doyen clamps on healthy sides around 3-5 cm from the area to be resected
-place carmalt clamps on the “throw-away” sides
-prepare for intestines to retract when cut; leave several cm beyond doyens
-double ligate blood vessels including arcuate and mesenteric vessels
-transect adjacent to the carmalts, between the arcuate ligations
What are the steps taken to correct luminal disparity?
-cut antimesenteric side of intestine
-trim corners to make an elongated opening
-trim excess mucosa that would otherwise interfere with apposition
-can recut or use interrupted sutures with angled spacing to align ends if luminal disparity continues after closure
What are the steps to placing positioning sutures?
-place the mesenteric and antimesenteric sutures, leaving the ends long
-place hemostats on the sutures and retract to align the two ends
What are the steps to suturing closed an anastamosis?
-if using a continuous pattern, work from the mesenteric margin to the antimesenteric margin and tie off to the antimesenteric positioning suture
-is using an interrupted pattern, subdivide the distance between the sutures; fill in the gaps with 2-4 additional sutures
-flip the intestine over to expose opposite side
-pass the ends of the mesenteric positioning suture through the gap and reattach hemostat
-start at mesenteric side and work toward antimesenteric suture; tie off
-perform a leak test
-lavage area before changing gloves/instruments
Why is it important to close the mesentary?
unclosed mesentery can allow for herniation of the intestines
What are the steps to apposing the mesentery?
-unroll the mesentery to identify the blood vessels to anastomosis
-close the defect with a continuous pattern while avoiding the blood vessels
-patch with omentum if the defect cannot be closed
What are potential complications of intestinal surgery?
-intestinal leakage
-ileus
-short bowel syndrome if removing more than 50-70% of intestine
How is a permanent adhesion formed?
-incise serosa and peritoneum
-suture seromuscular tissue to exposed body wall muscle
