Procedures Flashcards
Gastrotomy
Pack off the stomahc with moistened laparotomy sponges and stay sutures
Make an incision on the ventral surface of the stomach midway between the branches of the gastroepiploic and gastric vessels using a number 15 blade
Extend the incision with Metzenbaum scissors if needed
Change instruments and gloves prior to closure
Closure in several ways:
- Simple continuous appositional pattern through all layers
- Simple continuous patter in gastric mucosa followed by an inverting pattern in the seromuscular layer
Using monofilament absorbable suture material such as polydioxanone
Enterotomy
Pack out the small intestine with moistened laparotomy swabs
Make an incision into the small intestine immediately distal (aborally) to the foreign body with a number 15 blade
Remove the foreign body with an instrument and remove both foreign body and instrument from the sterile area
Change instruments and gloves prior to closure
Closure can be achieved with a simple interrupted or simple continuous pattern ensuring the incorporation of the submucosal layer as this is the holding layer of the intestine
Use a monofilament synthetic absorbable suture for closure (e.g. polydioxanone)
Resection and anastamosis
Pack out the small intestine with moistened laparotomy swabs
Carmalt forceps can be placed on the section of intestine that is being resected to prevent ingesta being spilled
Doyen forceps or the fingers of an assistant can be used to atraumatically prevent ingesta spilling from the ends to be anastomosed.
Ligate the blood vessels directly supplying the area of resection using triple ligation (two in the body and one on the area to be removed)
Remove the isolated section of bowel with several millimetres of viable bowel on either side
Change instruments and gloves prior to closure
Place one suture at the mesenteric border and one suture at the mesenteric border leaving the ends long.
The intestine can then be suture using a simple continuous pattern in two halves.
Use a monofilament synthetic absorable suture such as polydioxanone
Linear foreign body removal
Perform gastrotomy to identify the proximal end of the foreign body and attempt gentle traction to pull it into the stomach
If tethered in the small intestine, as evident by plication of the bowel, an enterotomy in this site is also required. Multiple enterotomies may be required to remove the foreign body.
Intussusception
Most common sites are enterocolic and enteroenteric
Spontaneous reduction is reported
Manual reduction may be possible with gentle traction but resection and anastamosis is often required due to non-viable portions of intestine
Enteroplication
Arrange the small intestine in gentle loops side by side from the duodenal colic ligament to the level of the ileum
Suture adjacent loops of intestine together engaging the submucosa
May decrease incidence of repeat intussusception
Complications include intestinal volvulus, intestine perforation with abscess formation and peritonitis
Rectal prolapse - medical reduction
Sedate or anaesthetise the patient and lavage the exposed tissue thoroughly with warm sterile saline and thenn reduction can be attempted
A purse string suture can be placed at the anal mucocutaneous junction taking care to avoid the anal sac ducts using monofilament non-absorbable synthetic suture
A spacer such as a 3-cc syringe can be placed in the rectum prior to tightening to allow space for soft stool to pass
Hyperosmotic agents can be applied to reduce tissue swelling
Rectal prolapse - surgical correction
Wide clip and sternal recumbency
Place a syringe within the rectal opening to assist with tissue layer identification
Identify at which level the tissues appear healthy near the anus and place four stay sutures proximal to this line (closer to the anus) incorporating both the outer everted rectum and inner everted rectum.
Incise through both layers in segments to improve tissue layer identification
Closure is achieved with 3-0 or 4-0 monofilament prolonged absorbable sutures using a simple interrupted pattern with full thickness bites to ensure the inclusion of the submucosa
Consider if a colopexy is indicated
Gastric Dilation and Volvulus - trocharisation
Clip and surgically prep an area over the abdominal wall in an area of palpable gaseous distension
Identify an area of tympany and introduce a 14 or 16 gauge over the needle catheter and remove the bung +/- stylet
Remove once the flow of gas has stopped
Gastric Distension and Volvulus - De-rotation
Typically twisted between 90 and 360 degrees in a clockwise fashion (confirmed if the stomach is covered by omentum)
Stand on the right hand side of the dog and use the right hand to grasp the pylorus and retract the pylorus ventrally whilst exerting downward pressure with the left hand on the visible part of the stomach
Gastric distension and volvulus - assessing viability
Monitor the serosa for 5- minutes prior to full assessment
If the wall is discoloured ( grey, green, purple or black), has area of seromuscular tearing or is thinner on palpation, ischaemia is present and necrosis is likely
A partial thickness (seromucular) incision can be made to assess for perfusion
Gastric vessels should be gently palpated for evidence of thrombosis and pulses.
Gastric distension and volvulus - gastric resection
Partial gastrectomy and primary closure
Packed off the stomach from the remainder of the abdomen and place stay sutures in healthy stomach wall
Ligated intact blood vessels to the area and sharply excise the affect portion of the stomach using a scalpel blade
Close in two layers using a synthetic absorbable suture such as polydioxanone. Mucosa and submucosa can be closed with a simple continuous pattern and then seromuscular layer are closed with a continuous or interrupted apposition or inverting pattern
Gastric distension and volvulus - incisional gastropexy
Identify the pyloric antrum
Make a 5cm seromuscular incision longitudinally in the pyloric antrum
Make a corresponding incision through the peritoneum and transverse abdominal muscle on the right body wall approximately 1/3 of the distance from the ventral to the dorsal midline and 3-4 cm caudal to the last rib
Manual oppose the pylorus to the body wall to visualise the best site
Suture the edges of the gastric wall incision to the body wall incision with two rows of simple continuous sutures usually synthetic absorbable material e.g polydioxanone starting dorsally at the cranial borders of the incisions.
