Principles of Abdominal Surgery Flashcards
Steps for working up a case
A. Make a list of the problems you identified from the patient history and PE
B. Write a list of DDX (differential diagnoses) for each problem
C. Not DDX that are common among the problems and consider which DDX are most likely for your patient
D. Make a diagnostic plan to determine which diagnosis/es is/are correct
E. Add any abnormalities you find as a result of your diagnostic tests to your problem list and list the DDX for these new problems
F. Repeat diagnostics until you’ve made a diagnosis
Know the normal so you recognize the abnormal of the following
A. Anatomy B. Physiology C. PE D. TPR E. Blood pressure F. PCV, TP, glucose, BUN, lactate
Normal TPR for a cat
T: 100-102.5
HR: 140-220 BPM
RR: 20-30 BPM
Normal TPR for a dog
- HR: 60-160 BPM
- RR: 10-30 BPM
- 100-102.5
Normal Blood pressure
100-150 mm Hg
Normal PCV/TP/Glucose/BUN/Lactate
- Glucose: 80-120 mg/dL about
- PCV/TP (35-55/5.5-8)
- BUN (10-30)
- Lactate (<2.5)
What should you consider when asking yourself when surgery should be performed for a patient?
- If it would be best if done…
- By a certain time
- Before or after a certain age
- Before or after other diagnostics or treatments
- Is it an emergency
What do you need to have skills and resources for in order to perform a surgery?
- Do the surgery AND
- Handle potential intra-op complications AND
- Manage the patient post-op
What systems should you consider before surgery?
- Hydration
- Electrolytes
- Cardiovascular system
- Respiratory system
- Renal function
- Nutritional status
- Infection
What potential risks or complications are common to all procedures?
- Anesthesia
- Hemorrhage
- Infection of the incision
- Infection internally at the site of procedure
- Dehiscence of the abdominal incision
- Dehiscence of the procedure’s incision (e.g. enterotomy)
- Seroma
What else do you need to prepare for and counsel to the client about besides risks common to all procedures?
- Risks specific to that procedure
- Recurrence or failure to resolve the problem
When are therapeutic antibiotics started, and for how long are they continued?
- Started at the time of diagnosis and continued for a duration appropriate for that condition (days/weeks/months)
When are prophylactic antibiotics given and discontinued?
- 30 min pre-op and q90 min intra-op
- Stopped at the end of the procedure
What is a common choice for prophylactic antibiotics at WSU?
- Cefazolin or cefoxitin
What could be an exception to starting Abx pre-op?
- If one of the surgical goals is to get a sample for culture, abx may not be started until the sample is taken
- This decision is made on a case-by-case basis
What is an exploratory laparotomy or celiotomy?
- Incise into abdomen and examine contents
Why do an exploratory laparotomy or celiotomy?
- Diagnosis and/or treat
Who can do an exploratory laparotomy or celiotomy?
- General practitioners and surgeons
How do you do an exploratory laparotomy or celiotomy?
- Be systemic and thorough
- Visualize and palpate all structures
- Know what normal looks like
- Explore the sameway every time
What do you do if you don’t find significant findings on an exploratory celiotomy?
- Biopsy organs/tissues of interest before closing the abdomen
What are three principles to keep in mind during celiotomy?
- Keep tissues moist with sterile saline! Cover with moist laparotomy pads, lavage.
- Isolate contaminated areas (contamination can mean bacteria or neoplasia)
- When done with contaminated areas, you should lavage, change gloves, and change instruments
What is considered a contaminated area with an exploratory celiotomy?
- Bacteria or neoplasia
What should you always do when you are finished with a contaminated area?
- Lavage, change gloves, and change instruments
Indications for abdominal cavity lavage
- Eliminate contaminants (bacteria or tumor cells), warm up the patient, improve visualization, find the source of hemorrhage (look for swirl of blood in saline)
-
How do you lavage the abdominal cavity in dogs and cats?
- Use warm, sterile saline with no additives
Why is it imperative to suction out fluid or blood before closure of the abdomen?
- If you have free fluid, bacteria can be quite happy
What are three major considerations for prioritizing multiple surgical procedures?
- Immediately life threatening first (i.e. patient might die before end of surgery) before non-immediately life threatening problems
- Clean before contaminated procedures
- Major before minor problem
What can be an exception for clean before contaminated procedures?
- Immediately life-threatening goes first, even if it’s contaminated
Why do you usually want to do a major before a minor problem?
- Want to make sure major problem is taken care of in case surgery has to be cut short for anesthetic complications
- Possibly do harder procedure when surgeon is still fresh
What could be some exceptiosn for minor vs major procedure?
- Minor procedure is fast
- Minor is clean and major is contaminated
What is the term for incising into something?
- otomy
What is the term for removing a part of something?
- ectomy
What is the term for making a temporary or permanent stoma into another organ or to the outside?
- ostomy
Linea suture size and type for <4.5 kg patient?
- 3-0 PDS
Linea suture size and type for 4.5-17 kg patient?
- 2-0 PDS
Linea suture size and type for 18-45 kg patient?
- 0 PDS
Linea suture size and type for >45 kg patient?
1 PDS
PDS generic name
Polydiaxanone
Closure pattern for the abdomen
- Simple continuous pattern in the linea with 6 throws (3 square knots) on each end
If your incision is off midline or in the caudal abdomen where the linea is narrow, what should you suture?
- External rectus sheath only
- DO NOT include rectus abdominus muscle, internal rectus sheath, or peritoneum as these don’t add to the strength of closure
What 8 things should you consider for postop care of all surgery patients?
- Monitoring
- Hydration and electrolytes
- Analgesia
- Antibiotics
- Nutrition
- Treat any underlying disease or concurrent problems
- Incision
- Exercise
Things to consider for monitoring
- TPR
- Mucous membranes
- CRT
- Pulse quality
- Blood pressure
- Pain
- Urination
- Defecation
- Also watch for complications specific to a patient’s disease process/surgery
Things to consider for hydration and electrolytes
- Fluid type, rate, and route
Examples of analgesia to choose
- Fentanyl CRI +/- Lidocaine +/- ketamine CRI
- Local analgesic (e.g. bupivicaine which lasts 4-6 hours or 72 hours as NOCITA or liposome encapsulated
- Tramadol (better for acute pain as with soft tissue sx than chronic ortho pain)
- NSAIDs (think first!)
What should you consider before starting NSAIDs on a patient?
- Are there concerns that the patient might become hypotensive?
- Any renal/liver/GI disease/GI surgery?
- Is it possible the patient might need steroids?
What are some indications that antibiotics may be needed?
- Infection present
- Marked contamination remains
- Extensive or severe tissue compromise
- Immunocompromised
Consideratiosn for nutrition
- When to start
- What to feed
- How much to feed
- Route (oral/feeding tube/parenteral)
Incision monitoring
- Monitor for redness, swelling, discharge, dehiscence
- Ice for first 24-72 hours, then +/- warm compresses
- Manage bandages and drains if present
Exercise restriction
- Type and duration of restriction
- Physical therapy
- Generally it’s limited leash walks and no running, jumping, or playing for 2 weeks
