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Y4 - Small Animals > Principles of GI tract, hepatobiliary + pancreatic surgery > Flashcards

Principles of GI tract, hepatobiliary + pancreatic surgery Flashcards

1
Q

What are Halsted’s principles?

A
  • Gentle tissue handling
  • Correct tissue apposition
  • Minimal tension
  • Obliteration of dead space
  • Strict asepsis
  • Meticulous haemostasis
  • Preservation of blood supply
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2
Q

How would you perform gentle tissue handling?

A
  • Treat the tissues you are working on as if they were your own
  • Make an incision of sufficient size
  • Allows thorough exploration
  • Makes surgery easier
  • Reduces tissue trauma
  • Hands for gut - avoid excessive handling = ileus
  • Keep tissues moist
  • Stay sutures
  • Use scalpel for initial incision into gut - extend with scalpel or metzenbaum scissors
  • Liver + pancreas are especially fragile / sensitive
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3
Q

What abdominal structures / organs do you need to evaluate in an exploratory coeliotomy?
What order should you look at them in?

A

1* Parenchymatous organs first = liver, spleen, pancreas, right kidney + adrenal, left kidney + adrenal
2* Intestines - stomach, duodenum, colon, caecum, ileum, jejunum, mesenteric lymph nodes
3* Bladder + uterus, reproductive tract (if present)
4* Anything else specific to the patient’s problem

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4
Q

How do you perform meticulous haemostasis?

A
  • Better to avoid haemorrhage if possible - Don’t cut major blood vessels!
  • Arrest haemorrhage as quickly and completely as possible = Ligatures + Electrocautery
  • Incise least vascular part of intestine = Halfway between greater and lesser curvatures of stomach
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5
Q

What are problems with haemostasis of the liver?

A
  • Extremely vascular
  • Hepatopathy can cause coagulopathies
  • Pringle manoeuvre = temporary occlusion of hepatic blood flow (15 mins)
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6
Q

What are problems with haemostasis of the pancreas?

A
  • Very vascular + fragile
  • Electrocautery can cause pancreatitis
    = Guillotine technique with encircling ligature, blunt dissect between lobules + individually ligate vessels + ducts
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7
Q

Why can’t you ligate the cranial rectal artery in dogs?

A
  • It is the only blood supply to rectum = rectum will go necrotic if ligated
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8
Q

Regarding preservation of blood supply, how would you assess intestinal viability?

A
  • Subjective criteria
    -Colour
    -Presence of arterial pulses
    -Ongoing peristalsis
  • Objective criteria
    -Pulse oximetry
    -Doppler ultrasound
    -Fluorescein dye and Woods lamp
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9
Q

What is the problem with oesophageal blood supply?
How would you preserve this?

A
  • Segmental blood supply
  • Rich submucosal plexus
  • Preserve this by:
  • Avoid excessive cautery
  • Handle tissue gently
  • Place sutures carefully
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10
Q

When performing strict asepsis what should be considered?

A
  • Gut lumen is contaminated -Stomach relatively sterile +
    Increasing bacterial population and proportion of anaerobes as you move down gut
  • Liver has resident population of clostridia
  • Stay sutures to immobilise tissues - Oesophagus + Stomach
  • Discard contaminated instruments and gloves before abdominal closure
  • Lavage abdomen before closure =
  • 1-3L warm sterile saline
  • NO antibacterials or disinfectants
  • Suction removal
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11
Q

Why would you perform prophylactic antibacterials?

A
  • Must be present in tissues when contamination occurs
  • Clavulanate-amoxicillin for general prophylaxis
  • Metronidazole for anaerobes
  • Amoxicillin + cefazolin actively excreted in bile
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12
Q

Tension is not usually a problem in intestinal surgery,
Most of intestine is highly mobile.
What are the 2 major exceptions?

A
  • Oesophagus - relatively immobile so anastomoses can be difficult
  • Colon during subtotal colectomy
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13
Q

What are the 2 main methods of making intestinal
incisions to allow accurate tissue apposition?

A
  • Longitudinal incision, longitudinal closure
  • Longitudinal incision, transverse closure
  • avoid transverse incisions + closure
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14
Q

How fast does most of the GIT heal by?

A
  • 75% of normal strength within 14 days
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15
Q

What is apposition of choice with oesophagectomy + enteroectomy?

A
  • End-to-end appositional anastomosis
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16
Q

What part of the GIT heals more poorly and why?

A
  • Oesophagus
  • incomplete serosal covering
  • poor vascularity
  • tension + motion
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17
Q

What suture material should be used with the GIT?

A
  • 1.5-2 metric (up to 3 in stomach)
  • Monofilament absorbable (PDS, Maxon, Monocryl)
  • Avoid multifilament - wicking, acts as nidus for bacterial growth
18
Q

What must the sutures incorporate and why?

A
  • Sutures must incorporate the submucosa =
  • Strongest layer
  • Accurate alignment of submucosa required for adequate healing
19
Q

What suture pattern should be used and why?

A
  • Appositional patterns (simple interrupted or
    continuous) are best
  • Technically easy and rapid
  • Preserve blood supply
  • Maintain luminal diameter
  • Minimal adhesions
20
Q

Why is continuous preferred to interrupted?

A
  • Less mucosal eversion
  • Less adhesions
  • Better submucosal apposition
21
Q

What suture patterns are used for the oesophagus?

A
  • Single or 2 layer closure
  • If 2 layers, deep layer in mucosa / submucosa with knots in lumen and superficial in serosa / muscularis with knots on serosal surface
22
Q

What suture patterns are used for the stomach?

A
  • 2 layer closure =
  • Simple continuous
  • Continuous inverting Cushing or Lembert
  • Alternatively, 2 layers of Cushing or Lembert
23
Q

Why would you not use cat gut to stitch GIT?

A
  • Will get digested
24
Q

If removing a foreign body from the intestines what could you do to reduce likelihood of infection?

A
  • Exteriorise + pack off incision site
  • Incise distal to foreign body + squeeze out
  • Close incision securely with a monofilament suture
  • Check for leakage after closing gut
  • Lavage abdomen before closure
  • Give prophylactic antibacterials
  • Change instruments before abdominal closure
25
Q

Why would you not do a side to side anastomosis?

A
  • Pouch formation
  • Dilation + rupture
26
Q

How would you perform obliteration of dead space?

A
  • Always suction out all lavage fluid
  • Always suture the mesentery if you’ve made a hole in it - otherwise intestines could become herniated in it and lose blood supply
27
Q

Why is fluid therapy needed?

A
  • GIT surgery often have fluid deficits, electrolyte + acid-base imbalances
  • Ongoing losses occur by evaporation from exposed viscera
28
Q

What can cause secondary peritonitis?

A
  • Chemical
  • Septic
29
Q

Why can peritonitis cause?

A
  • Hypovolaemia
  • Metabolic acidosis
  • Electrolyte imbalances
  • Endotoxic shock
  • Death
30
Q

What are clinical signs of peritonitis?

A
  • Depression
  • Anorexia
  • Vomiting
  • Abdominal pain and distension - “Praying” position
  • Ileus
  • Pyrexia
  • Shock
31
Q

How is peritonitis diagnosed?

A
  • Radiography
  • Haematology - Neutrophilia and left shift, Sometimes degenerative
  • Serum biochemistry - Azotaemia, hypoglycaemia
  • Abdominal paracentesis - Degenerate neutrophils, Free and/or intracellular bacteria, Compare lactate and glucose to serum
32
Q

How would you treat peritonitis?

A
  • Fluid therapy
  • Broad-spectrum antibacterials - Later based on culture and sensitivity
  • Correct primary cause - Exploratory coeliotomy
  • Copious peritoneal lavage -Dilution is the solution to pollution!
  • Drainage
33
Q

What is short bowel syndrome? How is it managed + prognosis?

A
  • Occurs after removal of >80% of small intestine
  • Medical management
  • Prognosis poor
34
Q

What is ileus? How is it treated?

A
  • Inadequate peristalsis of whole GIT leading to functional obstruction
  • Due to vagosympathetic reflex
  • Whole gut becomes distended and gas or fluid-filled
  • Treat by correction of underlying disease, supportive therapy (fluids, metoclopramide)
35
Q

What can be done during your daily clinical exam to monitor patients for postoperative peritonitis?

A
  • Check for abdominal pain by palpation - remember cats often don’t show this
  • Ballotte the abdomen for fluid thrill
  • Weigh them
  • Measure their abdominal circumference
36
Q

What would be your approach to the oesophagus?

A
  • Ventral cervical midline – for oesophagus to level of 2nd rib
  • Right intercostal thoracotomy at level of lesion
37
Q

How would you close a ventral midline coeliotomy?

A
  • Close linea alba
  • Single layer of simple continuous
    (appositional sutures in external sheath of rectus abdominis)
  • 5-10mm from edge and 3-12mm apart
38
Q

What are your approaches to the terminal colon, rectum + anus?

A
  • Ventral approach - Pelvic osteotomy / pubic symphysiotomy
  • Anal approach - Evert rectum with stay sutures
  • Rectal pull-through approach - Evert, transect, exteriorise, transect, anastomose
  • Dorsal “inverted U” approach
  • Lateral approach
39
Q

If you had a patient with a benign distal colonic / proximal rectal mass just inside the cranial end of the pelvis, What surgical approach would you use to access the affected intestine? Why?

A
  • Ventral midline coeliotomy
  • benign mass = so only require local excision
  • allows full-thickness resection
  • can usually retract that section of the intestine cranially and access vis the abdomen
  • avoids need to cut pelvis
40
Q
A

Y4 - Small Animals (105 decks)

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