Lecture 3: Surgery of the Stomach (Exam 1) Flashcards
Define gastrotomy
An incision through the stomach wall into the gastric lumen
Define partial gastrectomy
Resection of a portion of the stomach
Define gastropexy
Procedure that permanently adheres the stomach to the body wall
Define pyloroplasty
Full-thickness incision & tissue reorientation to increase the diameter of the gastric outflow tract
Define pylorectomy
Removal of the pylorus
Define gastroduodenostomy
Attachment of the stomach to the duodenum
Define Billroth I procedure
Pylorectomy + gastroduodenostomy
Define Billroth II procedure
Gastrojejunostomy + after partial gastrectomy (including pylorectomy)
Define pyloromyotomy
An incision through the serosa & muscularis layers of the pylorus only
What are the common indications for gastric surgery
- Foreign body removal
- Correction of Gastric Dilatation & volvulus (GDV)
What are some perioperative concerns during gastric sx
- Vomiting animals (dehydration, hypokalemia, aspiration pneumonia, & esophagitis)
- Alkalosis (secondary to gastric fluid loss) & metabolic acidosis
- Hematemesis (may indicate gastric erosion or ulceration but may also indicate coagulopathy
- Peritonitis from gastric perforation/rupture
How should food be with held for px going into gastric sx
- > 18 (pref 24) prior to sx
- 4 to 6 H for pediatrics when hypoglycemia is a concern
When should surgery for gastric obstruction, distension, malposition, or ulceration should be performed
As soon as the px has been stabilized
When could antibiotics not be necessary for perioperative to gastric sx
- Normal immune fxn
- Simple gastrotomy (proper aseptic tech & no spillage of gastric contents)
What bacteria is scarce in the stomach compared w/ the rest of the GI tract due to the low gastric pH
Helicobacter organisms
What are the parts of the stomach & where are they located
- Cardia - esophagus enters the stomach @ the cardiac ostium
- Fundus - Dorsal to the cardiac ostium
- Body - middle 1/3; lies against the left liver lobes
- Pyloric antrum - opens into the pyloric canal
- Pyloric canl
- Pyloric ostium - End of the pyloric canal that empties into the duodenum
What is the hepatogastric ligament
Portion of the lesser omentum that passes from the stomach to the liver
Label the following parts of the stomach:
What arteries are derived from the celiac artery? What do the supply
- The gastric - supplies the lesser curvature of the stomach
- The gastroepiploic - the lesser curvature of the stomach
What artery is derived from the splenic artery? What does it supply
The short gastric artery - supplies the greater curvature of the stomach
What can happen if the short gastric arteries are ruptured
- Blood loss (intraabdominal hemorrhage)
- Gastric infarction/necrosis
Describe the gastric mucosa
- Accounts for 1/2 the stomach weight
- Easily separated from the submucosa & serosa
T/F: Billroth procedures are easier & are not associated w/ as many complications
False they are more difficult & may be associated w/ severe complications
What is the preferred over surgical removal of FBs
Gastroscopy
Describe gastroscopy
- Preferred for mucosal biopsies since you can obtain more tissue samples from a variety of locations
- more sensitive when looking for erosions, physaloptera, & small lesions
- Can’t dx all lesions w/ gastroscopic biopsies
- Ventral midline approach
- Use balfour retractors
- Perform exploratory before incising the stomach
- Isolate the stomach w/ moistened laparotomy pads
- Place stay sutures
Describe place stay sutures
- Assist w/ manipulation
- Prevent spillage of gastric contents
What is the most common reason for gastrotomy in dogs & cats
Removal of a FB
Where is the gastric incision made
- A hypovascular area of the ventral aspect of the stomach
- Btw/ the greater & lesser curvatures
- Make sure it is not by the pylorus or closure of the incision may cause excessive tissue to be enfolded into the gastric lumen (outflow obstruction)
Describe the process of a gastrotomy
- Make a stab incision into the gastric lumen
- Enlarge the incision w/ metzenbaum scissors
- Use suction to aspirate gastric content (spillage)
- Close the stomach w/ 2-0 or 3-0 absorbable monofilament suture in a 2 layer inverting seromuscular pattern
What is in the first layer of a 2-layer inverting seromuscular pattern? What suture pattern would be used?
- Serosa
- Muscularis
- Submucosa
- Cushing or simple continuous
What is in the second layer of a 2-layer inverting seromuscular pattern? What suture pattern would be used?
- Serosal
- Muscularis layer
- Lembert or cushing
Label the following suture patterns
What should be done prior to closing the abdominal wall in a gastrotomy
- Change gloves
- Use sterile instruments
- Check the rest of the GI tract for something that could cause an obstruction
A red to purple seromuscular layer shows (nonviable/viable) stomach while a green to black seromuscular layer shows a (nonviable/viable)
Viable; nonviable
But observation of the mucosal color is not a reliable indicator
What else can be done to determine the gastric viability
- Fluorescein dye (unreliable @ low flows)
- Palpate thickness in antrum compared to dorsal fundus
- Bleeding in response to incision
What does it mean if the antrum feels thin
The tissue is necrotic
When is a partial gastrectomy done
- When necrosis, ulceration, or neoplasia involves the greater curvature or middle portion of the stomach
How is necrosis associated w/ GDV treated
W/ resection or invagination
Describe an invagination of a necrotic stomach
- Don’t have to open the gastric lumen
- Obstruction is possible from excessive intraluminal tissue
- Excessive hemorrhage is possible
- Melena commonly observed a few days after gastric invagination
What are indications for Billroth 1 procedure
- Neoplasia (1 to 2 cm margins of norm tissue should be removed w/ abnorm tissue; margins of the resected tissue should be evaluated histologically)
- Outflow obstruction caused by pyloric musclular hypertrophy
- Ulceration of the gastric outflow tract
What are some complication of a Billroth I procedure
- If the common bile duct has been damaged a cholecystoduodenostomy or cholecystojujunostomy my be req
- If the pancreatic ducts are inadvertently ligated, supplementation w/ pancreatic enzymes may be necessary postop
What is different about a billroth II procedure
The distal stomach & proximal duodenum are closed after pylorectomy & the jejunum is attached w/ a side to side anastomosis to the diaphragmatic surface of the stomach
What are the indications for a billroth II procedure
- Neoplasia
- Outflow obstruction caused by pyloric muscular hypertrophy
- Ulceration of the gastric outflow tract
If the extent of the lesion precludes end to end anastomosis of the pyloric antrum to the duodenum what procedures be considered
Billroth II procedure
What are some complications of a billroth II procedure
- A cholecystojejunostomy or cholecystoduodenostomy is req in addition to the gastrojejunostomy
- Exocrine insufficiency may occur if the pancreatic ducts are damaged. Exocrine plus endocrine pancreatic insufficiency may occur as a result of pancreatic resection of severe damage to the pancreatic blood supply
Describe a pyloromyotomy & pyloroplasty
- Increase diameter of the pylorus
- Used to correct gastric outflow obstruction (chronic antral mucosal hypertrophy & pyloric stenosis)
- Difficult/impossible to reverse (may actually slow gastric emptying if not indicated
- Not for routine use w/out evidence of pyloric dysfunction
Describe a Fredet-Ramstedt Pyloromyotomy
- Simplest & easiest procedure
- Does not allow inspection or biopsy of pyloric mucosa
- Probably only temporary benefit (healing my reduce lumen size)
Describe Heineke-Mikulicz Pyloroplasty
Allows limited exposure of the pyloric mucosa for inspection & biopsy
Describe a Y-U Pyloroplasty
- Allows greater accessibility for resection of the pyloric mucosa in dogs w/ mucosal hypetrophy
- If mucosa was resected appose the remaining mucosal edges in a continuous pattern
- Increases the luminal diameter of the outflow tract
- To reduce necrosis @ the pointed tip of the gastric tissue flap, the point of the “Y” may need to be excised before suturing it
Why do gastric FBs usually cause vomiting
- Gastic outflow obstruction
- Gastric distension
- Gastric mucosal irritation
T/F: Gastric FBs may be asymptomatic w/ incidental radiographic findings
True
Who more commonly ingest linear foreign bodies
*Cats
* Thy are frequently anchored under the tongue or @ the pylorus & often cause intestinal plication
What are some important considerations for gastric FBs
- Initial clinical sx may not alert the owner to seriousness of the condition
- Linear foreign objects must be removed as soon as possible to avoid intestinal perforation & peritonitis
- Not all animals w/ gastric foreign objects vomit
- Finding a foreign object in the stomach does not guarantee that it is the cause of vomiting
- Linear FBs are more common in cats (always check under the tongue)
- Most gastric FBs can be removed endoscopically
- Complete exploration of the entire intestinal tract is mandatory in surgical px
- Always repeat the radiographs imm before surge to make sure that the object has not moved
T/F: Opening the colon is always justified
False it is seldom justified
