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SA Surgery > SAMS 1 > Flashcards

SAMS 1 Flashcards

1
Q

Sterilization

A

process of destroying all microorganisms

chemical, heat or radiation

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2
Q

T/F: only inanimate objects can be entirely sterile

A

true

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3
Q

disinfectants vs. antiseptics vs decontamination

A

Disinfectants- on inanimate objects

antiseptics- antimicrobials on LIVING TISSUE

decontamination- cleaning & disinfecting/ sterilizing processes to make contaminated things safe to handle

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4
Q

Asepsis vs sterile

A

asepsis- absence of pathogenic microorganisms

sterile- free off ALL microorganisms

sterility- surgery suite!
asepsis- whole hospital

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5
Q

T/F: infection rate doubles for every hour of surgery

A

TRUE!!!

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6
Q

clean wound

A

Non- traumatic
ELECTIVE PROCEDURE
no acute inflamamtion
no break in aseptic technique
no entry into nasty organs (GI, urinary or respiratory)

INFECTION RATE IS 2.5-6%

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7
Q

clean contaminated wound

A

entry into GI, urinary or urogenital tract WITHOUT significant contamination

minor break in asepsis

INFECTION RATE- 2.5-9%

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8
Q

contaminated surgery

A

fresh traumatic wound (less than 4 hours old)

leakage from GI or urogenital tract

MAJOR BREAK IN ASEPSIS

INFECTION RATE 5.5-28%

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9
Q

dirty surgery

A

infected

traumatic wound over 4 hours old OR TISSUE IS DEVITALIZED OR FOREIGN MATERIAL

perforated viscus encountered

acute bacterial inflammation or purulent material (pus)

“clean” tissue transected for access to an abscess

INFECTION RATE 18-25%

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10
Q

whats the difference between eyed and swaged needles

A

eyed: MORE TRAUMATIC! unreels easily

swaged on: expensive, much less traumatic

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11
Q

Cutting suture needles

A

FOR FIBROUS TISSUE (periosteum, fascia, skin)

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12
Q

standard cutting needle vs. reverse cutting needle

A

standard: cutting edge toward incision -> larger hole and more risk of suture pull through

reverse cutting: edge away from incision -> less risk of bigger hole and pull through; also doesn’t get dull as fast apparently

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13
Q

taper needles

A

DELICATE TISSUES (bladder, GI, muscle, fat)

anything w. a lumen or a subq layer

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14
Q

natural vs. synthetic suture

A

natural (cat gut or silk) has an intense inflammatory reaction in the tissue and synthetic doesnt

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15
Q

absorbable vs. non-absorbable

A

absorbable: loses strength in 60-90 days using enzymatic or hydrolytic degradation

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16
Q

faster degradation of suture

A

urine (sterile): PDS- loses all strenght in 3 days; 1 day if proteus is in the urine

PDS, monocryl, maxon and biosyn lose all strenfht in tissues in 7 days if proteus is present

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17
Q

PH and suture degradation

A

faster in Alkaline: Monocryl, Maxon, Biosyn, Vicryl, Dexon

ACIDIC: pds, vicryl and non-absorbable nylon

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18
Q

which type of suture is resistant to loss of strength regardless of tissue ph

A

polypropylene- non-absorbable suture

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19
Q

monofilament suture

A

single strand, less drag through the tissues, MEMORY, resists harboring microorganisms, more susceptible to breaking

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20
Q

multifilament suture

A

multiple strands
stronger and more pliable
less memory

more drag and increased risk for infection

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21
Q

what is the most common antibiotic coating for sutures

A

triclosan

inhibits bacterial FA synthesis

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22
Q

suture creep

A

the tendency to slowly and permantly deform under constant streess

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23
Q

suture memory

A

tendency to return to og shape after deformation

when you take out of the package and it just wants to coil back up

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24
Q

PDS suture

A

monofilament
absorbable
coated or uncoated

use for:
body wall/ fascia and muscle
ligatures (spay and neuter
stay sutures

small dog- 3-0
md dog: 2-0
lg dog: 0 to 2-0

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25
Q

Maxon suture

A

similar to PDS

monofilament, absorbable, uncoated

body wall/ fascia & muscle, ligatures, stay sutures

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26
Q

monocryl suture

A

monofilament, absorbable, coated/ uncoated

SUBCUTANEOUS TISSUE
SKIN

small dog: 3-0 to 5-0
md: 2-0 to 4-0
lg dog: 2-0 to 3-0

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27
Q

biosyn suture

A

monofilament, absorbable
uncoated
similar to monocryl

SUBCUTANEOUS OR SKIN ONLY

sm dog: 3-0 to 4 or 5-0

md: 2-0 to 3 or 4-0
lg: 2-0 to 3-0

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28
Q

vicryl suture (polyglactin 910)

A

BRAIDED, absorbable
coated

SOFT TISSUE APPROXIMATION/ LIGATION, OPTHALMIC SX, INTRAORAL SX

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29
Q

nylon suture

A

braided or monofilament
NON-ABSORBABLE

SKIN, DRAINS/ TIE-OVERS, TUBES

INTENTIONAL SHUNTS

SKIN:

sm: 3-0 to 4-0
md: 2-0 to 3-0
lg: 2-0 to 3-0

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30
Q

polypropylene suture

A

similar to nylon

monofilament
non-absorbable

SKIN (sm: 3-0/ 4-0 md & lg: 2-0/3-0)
DRAINS/ TIE-OVERS/ TUBES

INTENTIONAL SHUNTS

VASCULAR: LEAST THROMBOGENIC OF ANY SUTURE

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31
Q

which suture type is the least thrombogenic

A

polypropylene

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32
Q

list suture types you would use for skin

A

polypropylene
nylon
biosyn
monocryl

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33
Q

list sutures you would consider for ligatures or stay sutures

A

PDS
maxon

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34
Q

what suture type would you use for subcutaneous tissue

A

biosyn
monocryl

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35
Q

what suture type would you use for the body wall or fascia

A

pds
maxon

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36
Q

what suture would you use for opthalmic or oral surgery

A

vicryl

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37
Q

T/F: interrupted suture patterns provide a better seal

A

false!

continuous is better

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38
Q

list some examples of appositional interrupted suture patterns

A

simple interrupted
cruciate
gambee (I/C)

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39
Q

list some inverting suture patterns

A

Halsted

Lembert

Cushing: partial thickness

Connell: full thickness (L is for lumen)

INVERTING: TURNS TISSUE EDGES TOWARD CENTER OF HOLLOW ORGAN

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40
Q

list examples of everting/ tension relieving suture patterns

A

Quilled/ stented: I
Far- Near- Near-Far: I
Vertical Mattress: I/C
Horizontal Mattress: I/C

TURNS TISSUES AWAY FROM THE PATIENT AND TOWARD THE SURGEON

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41
Q

chinese finger trap for a drain

A

secures tubes in place

repeated loops around the tube

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42
Q

purse string suture patterns

A

to secure a tube that’s exiting the body

Contraindicated:
GI or any organ that can stricture

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43
Q

where should tissue adhesive (vetbond) NEVER GO

A

never ever put it in the subcutis or inside the body

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44
Q

t/f: the knot of a suture does not reduce tensile strength

A

FALSE

KNOTTING REDUCES STRENGTH BY 10-40%

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45
Q

when you hand a surgeon a curved kelly hemostat which way should the tips point?

A

UP

so they are ready to be used!

ALSO SLAM IT INTO THEIR HAND

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46
Q

What labwork must be done prior to a spay/neuter

A

CBC, Chem

MUST HAVE PCV/TP AND GLUCOSE

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47
Q

An ovariohysterectomy will decrease the risk of mammary neoplasia. What is the risk of cancer if they are spayed after their 1st heat

A

BEFORE 1ST: 0.05%

after 1st heat: 8&

after 2nd heat: 26%

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48
Q

list the gutters for an ovariohysterectomy

A

kidneys
ureters
urinary bladder

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49
Q

what are the biologic retractors for an overiohysterectomy

A

descending duodenum - right side

descending colon- left side

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50
Q

describe the surgical approach for an ovariohysterectomy

A

caudoventral midline approach

dogs: middle of the cranial 3rd to the middle of the middle 3rd
cats: middle 3rd

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51
Q

ovariohysterectomy anatomy in dogs vs. cats

A

DOGS: short ovarian pedicle, long uterine body

CATS: long pedicle, short body

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52
Q

if you cant get the uterine body out with the spay hook what should you do next

A

gently lift the bladder up

the uterine body is between the bladder and the colon

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53
Q

list the steps for an ovariohysterectomy after you have made the incision and disected through the linea alba

A
  1. use snook OHE hook to get the uterine horn out then follow that to the ovary
  2. place a mosquito hemostat on the proper ligament
  3. exteriorize the ovary by plucking the suspensory ligament (can cut it too)
  4. make a window in the broad ligament (watch out for the ovarian artery and veins)
  5. place 1st hemostat proximal to the pedicel
  6. place 2nd hemostat just proximal to the ovarian bursa
  7. circumferential ligature just underneath the 1st hemostat
  8. replace the hemostat distally (toward the ovary)
  9. circumferential ligature proximal to the hemostat
  10. flash the hemostat when tightening
  11. transect the pedicle above the hemostat using a scalpel blade
  12. controlled release
  13. same on other pedicle
  14. tear broad ligament parallel to the uterine horn to the cervix (both sides)
  15. clamp distal to the cervix (dogs only)
  16. place 2nd hemostat 5mm distal to the 1st
  17. place a 3rd hemostat further distal
  18. circumferential ligature proximal to the 1st hemostat and remove hemostat while tightening
  19. transfixation ligature
  20. transect uterine body
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54
Q

when closing what is the holding layer

A

external rectus fascia

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55
Q

describe a 3 layer closure

A

abdominal wall (linea alba) using simple interrupted pattern w/ PDS or Maxon

subcutaneous tissue simple continuous pattern using monocryl or biosyn

skin closure using intrademal pattern with monocryl or biosyn

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56
Q

when do we hot pack/ cold pack

A

cold pack for the first 3 days then hot pack for the next 3 days

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57
Q

describe the prescrotal closed orchiectomy approach

A

dont go into the peritoneal cavity

ligature may be more likely to slip

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58
Q

describe an open prescrotal orchiectomy

A

opens the peritoneum

more direct exposure of the cord

some people prefer this for larger dogs

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59
Q

list the principles of urinary tract surgery

A

GENTLE TISSUE HANDLING (stay sutures, debakey forceps or fingers)

magnification

hemostasis

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60
Q

suture selection for urinary tract sx

A

absorbable monofilament suture: PDS or monocryl

3-0 to 5-0

AVOID CONTACT W/ URINE

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61
Q

list the anatomomic retractors for the upper urinary tract

A

mesoduodenum

mesocolon

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62
Q

what is the blood supply to the kidney

A

renal artery (10% have miltiple L renal arteries and only one R renal artery)

renal vein ( left ovarian/ testicular vein drains to it; cats usually have multiple)

lumbar lymph nodes

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63
Q

describe renal neoplasia

A

usually malignant

renal carcinoma in dogs

lymphoma in cats

bilateral in 30% of dogs w. primary neoplasia (PN is uncommon)

mets to: liver, adrenals, lungs, LN’s, bone and brain

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64
Q

renal biopsy

A

rarely done bc it damages the kidneys

helps w. diagnosing

only get cortical tissue

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65
Q

nephrotomy

A

cutting into the kidney

removing OBSTRUCTIVE nephroliths or neoplasia

AVOID: severe hydronephrosis

may compromise renal fxn by 25-50%

midline celiotomy approach

make sure to occlude the vessels using a tourniquet or a clamp

close w/ simple continuous pattern (absorbable suture)

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66
Q

nephrectomy

A

removing the kidney

midline celiotomy

reflect medially for better visualization of vessels

ligate and transect arteries and veins seperately

triple ligate with 2-0 or 3-0 PDS

isolate the ureter at the bladder and double ligate the bladder as close to the bladder as possible with 3-0 PDS

pull on kidney to remove the ureter from the retroperitoneum

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67
Q

pyelolithotomy

A

removing part of the renal pelvis

if its obstructed by renal or ureteral calculus

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68
Q

what is the blood supply to the ureter

A

renal artery Cranially

prostatic or vaginal artery caudally

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69
Q

describe an ectopic ureter

A

one or both of them dont empty into the dorsovental bladder wall (uusally enter at the neck or lower)

more in females

huskies, goldens, labs, mini poodles, terriers

JUVENILE ANIMAL THAT HAS BEEN INCONTINENT SINCE BIRTH

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70
Q

INTRAMURAL ectopic ureter

A

enters bladder normally

+/- ureteral orifice at the trigone

ureter CONTINUES BEYOND THE PAPILLA (submucosal tunnel)

empties caudal to the trigone

MOST COMMON IN DOGS

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71
Q

EXTRAMURAL ectopic ureter

A

completely misess the bladder

CATS

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72
Q

URETEROTOMY

A

usually for a stone

find the stone then make a longitudinal incision over it

flush the ureter then close longitudinally or transversly

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73
Q

ureteral R&A

A

sharp transection

spatulate the ends (widens the anastomosis and decreases stricture risk)

close w/ interrupted or 2 continuous lines

absorbable suture (PDS or monocryl; 4-0 to 5-0)

consider stenting to prevent stricture

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74
Q

neoureterostomy

A

intramural ectopic ureters

ventral midline celiotomy

ventral cystotomy- possibly extend into the urethra

Catheterize ureter

incise over the cather in trigone/ ureteral papilla area

suture mucosa together (make new stroma)

ligate distal to the new stoma

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75
Q

neoureterocystostomy

A

ureteral re-implantation for extramural E.U., distal ureteral injury, neoplasia

ventral midline celiotomy

ligate & transect near the bladder/ urethra

tunnel through body then make stab incision into mucosa

spatulate the ends then suture to the bladder mucosa with 3-5 simple interrupteds w/ 4-0 to 5-0 PDS or monocryl

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76
Q

what are some post-op considerations after upper urinary tract sx?

A

persistent incontinence in 30-55% of patients (especially in huskies)

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77
Q

what are some potential complications with kidney sx?

A

renal failure
hemorrhage
urianry leakage
hematura
hydronephrosis

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78
Q

what are some potential post op complications with ureteral sx?

A

stricture

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79
Q

what is the blood supply to the bladder

A

supply is dorsolaterally to the bladder (via lateral ligaments)

cranial vesicular artery

caudal vesicular artery-> MAJOR BLOOD SUPPLY; branch of the urogenitial artery

internal pudendal vein

sublumbar LN’s

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80
Q

describe the innervation to the bladder

A

sympathetic: hypogastric nerve (L1-4)
parasympathetic: pelvic n (S1-3)
somatic: pudendal n (L7-S3)

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81
Q

describe the healing process of the nladder

A

100% strength is regained by 14-21 days

complete re-epitheliazation by day 30

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82
Q

describe the healing process of the urethra

A

heals by 7 days

have to divert urine to prevent complciations)

complete transection often leads to stricture (can place catheter to help)

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83
Q

describe retrograde hydropulsion

A

patient anesthetized to relax the urethra the best

catheterize to the stone

2nd person puts a gloved finger in the rectum and occludes the urethra proximal to the stone

flush w/ saline to distend urethra

assistant quickly released the urethra to let the stone pass

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84
Q

describe voiding urohydropulsion

A

very tiny stones or grit

anesthetize patient

catheterize

fill bladder w/ saline

hold ptnt upright and express bladder

DO NOT RUPTURE THE BLADDER

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85
Q

Cystotomy

A

caudal abd midline or parapreputial celiotomy

exteriorize the bladder; use stay sutures at the apex and pack off the bladder

stones: pass a catheter before cutting into the bladder to prevent them from falling down into the urethra

incise at ventral midline and mid body

stab incicion then suction urine out

extend incision w/ metzenbaums

place stay sutures to hold it open

goal of closure: watertight seal without impinging ureters

SUBMUCOSA IS THE HOLDING LAYER

single layer closure is preferred (3-0 PDS/ monocryl with simple interrupted or simple continuous)

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86
Q

t/f: a small amount of hemorrhage up to 1 week post op is normal after a cystotomy

A

true

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87
Q

cystostomy

A

opening into bladder for urine diversion

mini-celiotomy over bladder

stay sutures

stab incision through bladder wall

place a tube, then tighten a purse string suture pattern, pass tube through body wall ( seperate incision), inflate the balloon

close and suture catheter to the skin

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88
Q

urethrotomy

A

catheterize

incise the urethra over the catheter

extend incision w. iris scissors

closure is preferred ( simple interrupted or simple continuous using 3-0 or 4-0 PDS/ monocryl)

can leave to heal by 2nd intention and can bleed for several days

remove catheter

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89
Q

urethrostomy

A

permanent hole in the urethra

scrotal, perineal, prescrotal, prepubic

scrotal is preferred for dogs

perineal is preferred for cats

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90
Q

scrotal urethrostomy

A

dogs!

urethra is widest and most supf here

castration w/ scrotal ablation

catherize

ventral midline incision over urethra

mobilize and retract the retractor penis muscle

make a 2-3cm long urethral incision over the catheter

suture urethral mucosa to the skin (simple interrupted or continuous 3-0 or 4-0 monocryl

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91
Q

perineal urethrostomy

A

CATS!

catheterize

incise around scrotum and prepuce
mobilize penis/ urethra to the level of the bulbourethral glands (dissect laterally and ventrally; minimal dorsal dissection; release ischiocavernosus muscle)

incise @ bulbourethral glands (widest at this point in cats)

amputate the penis

suture the urethral mucosa to the skin w. 4-0 monocryl using a simple interrupted patter

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92
Q

where is the widest point of the urethra in the male dog? what about cats?

A

Dogs: scrotal section of the urethra

cats: bulbourethral glands

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93
Q

list potential complications of a urethrostomy

A

stricture formation

urine leakage (uroabdomen or subcutaneous tissue)

ascending bacterial infection

hematuria/ hemorrhage

urinary/fecal incontinence

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94
Q

urethral prolapse is most common in

A

english bulldogs, bostons, and yorkies

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95
Q

urethral prolapse treatment

A

conservative: reduce the prolapse and place purse string sutures for 5 days
surgical: resect the prolapsed tissue, suture mucosa to the penis w/ simple interrupted 3-0 or 4-0 monocryl
urethropexy: mattress sutures to hold it in the penis

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96
Q

t/f: a urethral prolapse will recur if the animal doesnt get neutered

A

TRUE!!!!!!

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97
Q

t/f: hemorrhage is common after a urethral prolapse

A

true

hemorrhage for 1-2 weeks

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98
Q

List the primary components of brachycephalic airway syndrome

A

stenotic nares

elongated soft palate

hypoplastic trachea

nasopharyngeal turbinates

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99
Q

list the secondary components of brachycephalic airway syndrome

A

everted laryngeal saccules

laryngeal collapse

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100
Q

list some signs of brachycephalic syndrome

A

stertor
stridor
gagging
snoring
increased Resp effort
exercise intolerance
hypoxemia
hyperthermia

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101
Q

what are treatment options for stenotic nares

A

alaplasty (resecting the nares)

can be vertical, horizontal or dorsolateral

most people do vertical

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102
Q

describe an elongated soft palate

A

overlaps the epiglottis by more than 1-2 mm

normal caudal border is the caudal margin of the pharyngeal tonsils

soft palate helps to occlude the nasopharynx while swallowing

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103
Q

what is the name for resecting an elongated soft palate (surgical procedure)

A

staphylectomy

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104
Q

list some complications of a staphylectomy

A

post op swelling -> dyspnea

overshortening -> nasal reflux or aspiration

hemorrhage

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105
Q

how do everted laryngeal saccules form?

A

2ndary effect of increased negative pressure

eversion of mucosal tissue lateral to the vocal folds

contributes to upper airway obstruction

tx: sharp excision following extubation

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106
Q

what is a hypoplastic trachea

A

congenital issue in brachycephalic breeds (bulldogs esp)

decreased ratio of tracheal diameter: thoracic inlet height

NO SURGICAL TX AVAILABLE

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107
Q

laryngeal collapse

A

2ndary to negative pressure in airway

no good tx for severe cases: artenoid lateralization, partial laryngectomy, permanent tracheostomy

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108
Q

while nasal cavity surgery is not common, what are some approaches

A

dorsal rhinotomy

ventral rhinotomy

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109
Q

describe laryngeal paralysis

A

congenital issue in 4-6 mo old huskies or bouvier des flandres

acquired in large breed dogs (labs) and usually bilateral

traumatic -> usually bilateral

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110
Q

what are c/s of laryngeal paralysis

A

inspiratory stridor worse w/ exercise

voice change

exercise intolerance

resp distress/ hyperthermia

coughing when eating/drinking

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111
Q

how do we surgically correct laryngeal paralysis

A

“tie back”

UNILATERAL arytenoid lateralization (bilateral increases risk of asp. pneumonia)

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112
Q

what are the landmarks for arytenoid lateralization

A

caudodorsal part of cricoid cartilage

cricoarytenoid dorsalis muscle

muscular process of the arytenoid cartilage

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113
Q

list some complications of arytenoid lateralization

A

aspiration pneumonia (20% of ptnts)

dysphagia

suture breakage

cartilage fracture intra-op

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114
Q

temporary tracheostomy

A
  • upper airway obstriction
  • long-term ventilation
  • ventral midline cervical incision
    • seperate sternohyoideus muscles
    • incise annular ligament between cartilage rings between rings 3 &4 or 4&5
    • no more than ½ circumference of the trachea
    • stay sutures proximal and distal in the trachea
      • insert and maintain tube
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115
Q

what are some indications for permanent tracheostomy

A

upper airway obstriction

SALVAGE PROCEDURE

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116
Q

permanent tracheostomy

A
  • ventral midline cervical incision
  • seperate sternohyoideus muscles
  • appose sternohypodeus muscles dorsal to the trachea
  • excise rectangular segment of tracheal wall
    • LEAVE MUCOSA INTACT
  • suture mucosa to skin
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117
Q

what are the indications to tracheal R&A

A

neoplasia (rarely)

severe trauma

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118
Q

how much of the trachea can be resected

A

up to 50%

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119
Q

what are some complications of a tracheal R&A

A

stenosis

dehiscence

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120
Q

T/F: the intercostal space is 4 times as wide as the ribs

A

False

2-3 times

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121
Q

What is the main source of blood supply to the thoracic wall

A

intercostal arteries (caudal to ribs w/ vein and nerves)

internal thoracic artery runs at the ventrum

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122
Q

what intercostal muscle is involved in expiration (internal or external)

A

INTERNAL

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123
Q

What intercostal muscle is involed in inspiration (internal or external)

A

EXTERNAL

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124
Q

LIST THE MUSCLES INVOLVED IN INSPIRATION

A

scalenus

serratus dorsalis cranialis

levatores costarum

diaphragm

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125
Q

why would you perform a lateral (intercostal) thoracotomy

A

lung lobestomy, cardiac dx, thoracic duct ligation, esophageal/ tracheal sx

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126
Q

list some reasons why we may do a median sternotomy

A

thoracic exploratory

mediastinal mass resection

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127
Q

list some reasons why we may do a thoracoscpy

A

thoracic exploratory

pericardial window

lung lobectomy

thoracic duct ligation

mediastinal mass resection

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128
Q

how would you perform a lateral thoracotomy

A

incise from the costovertebral junction to the sternum

use a finochietto retractor

place a chest tube at caudorsal thorax

pre-place sutures: circumcostal w/ monofilament suture, remove air, appose muscles and skin, remove air again

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129
Q

which muscles are involved with a lateral thoracotomy

A

latissimus dorsi (elevate and retract DO NOT CUT)

scalenus (5th rib)

serratus ventralis seperate between muscle fibers)

intercostal muscles (seperate)

pleura

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130
Q

describe a median sternotomy procedure

A

incise at ventral midline over the sternum

through the pectoral musculature

transect the sternum (oscillating saw, avoid internal structures, leave 2-3 cranial or caudal sternebrae intact)

close: chest tube subcostal lateral to midline

ortho wire in an firgure 8 pattern

close normally

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131
Q

typical exploratory thoracoscopy

A

paraxyphoid camera portal w/ 5-10mm rigid scope

1-2 intercostal instrument portals

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132
Q

what is the purpose of a thoracocentesis

A

to remove fluid/ air

DO IT BEFORE RADS OR PLACING A CHEST TUBE

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133
Q

What sedation do you use for a thoracocentesis

A

opiod + benzodiazepine

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134
Q

which intercostal spaces do you perform a thoracocentesis in

A

7th,8th or 9th

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135
Q

t/f: most patients w/ a pneumothorax will resolve without surgery

A

true!

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136
Q

where do you incise for a trocar- style chest tube vs a large bore silicone chest tube?

A

trocar style: cut at 10th or 11th space then advance tube 3-4 spaces

Lg bore: pull incision cranially so incise directly over the entry space (`6/7th) then pop through intercostals w/ a curved hemostat. advance tube cranially then secure to animal

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137
Q

list some potential causes of a SPONTANEOUS PNEUMOTHORAX

A

ruptured bullae or blebs

commone in large breed dogs (HUSKIES!!!)

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138
Q

DESCRIBE MEDICAL MANAGEMENT VS SURGICAL OPTIONS FOR A SPONTANEOUS PNEUMOTHORAX

A

Conservative: continuous drainage over 2-3 days

surgical: complete or partial lung lobectomy (many dogs have multiple lesions and are bilateral so a thoracoscopy or median sternotomy)

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139
Q

describe an exudate

A

protein > 3g/dL

specific gravity is >1.025

nucleated cell count >7000

so protein, sp gravity and nucleated cell count is high

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140
Q

describe a modified transudate

A

protein > 2.5 but less = 5

specific gravity >1.015 = 1.025

nucleated cell count >1500 = 7000

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141
Q

describe a transudate

A

protein = 2.5

sp. gravity <1.015

NCC = 1500

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142
Q

what causes a chylothorax

A

anything that can increase hydrostatic pressure in the cranial vena cava

trauma, neoplasia, IDIOPATHIC IS MOST COMMON

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143
Q

describe a chylothorax (typical signalment and c/s)

A

afghans, shiba inus, siamese and himalayan cats

c/s: coughing &/or resp distress

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144
Q

what are some diagnostics you can do for a chylothorax

A

milky fluid w/ pink hue

fluid triglyceride > serum triglyceride

fluid cholesterol < serum cholesterol

chylomicrons → sudan black

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145
Q

describe medical management for a chylothorax

A

periodic thoracocentesis (can result in dehydration and loss of lipids, protein & fat soluble vitamins)

low fat diet

rutin (neutraceutical)

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146
Q

describe surgical management for a chylothorax

A

divert lymphatic flow from the thorax

METHYLENE BLUE IMPROVES INTRA-OP VISUALIZATION

thoracic duct ligation or pericardiectomy→ thoracoscopy or thoracotomy

cisterna chylii ablation → abdominal incision

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147
Q

what is the prognosis for a chylothorax

A

fair to guraded (53-100% success)

recurrence is most common complication

salvage procedures: pleuroperitoneal shunt or a pleuroport

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148
Q

describe the inital theraoy for acute traumatic diaphragmatic hernias)

A

assess for other injuries

treat for shock

resp support

emergency surgery if gastric herniation, unable to stabilize patient or uncontrollable pain/ hemorrhage

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149
Q

how would you surgically correct a diaphragmatic hernia

A

ventral midline celiotomy

replace abdominal contents

extend hernia if you need to

if there are adhesions (chornicity) then divide and possibly do a partial lung/ liver lobectomy; may need to do a caudal median sternotomy; be sure to debride edges if it is chronic

simple continuous duture (begin dorsally)

then suck the air out

85% or better chance of survival

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150
Q

what are some differentials for a mediastinal mass

A

thymoma

dogs more common

labs and goldens

10.5-12 years old

lymphoma

cats more common

~6 years old

151
Q

what are some signs of a mediastinal mass

A

weakness, anorexia, lethargy, coughing, dyspnea, weight loss, tachypnea, vomiting, regurgitation, PU/PD

152
Q

what is a common paraneoplastic syndrome with thymomas

A

myasthenia gravis (~50%)

and secondary megaesophagus

hypercalcemia

153
Q

what is a common paraneoplastic syndrome with lymphoma

A

hypercalcemia

154
Q

what are some further diagnostics that you can do for a thymoma to check for paraneoplastic syndrome (myasthenia)

A

AChR→ acetylcholine receptor antibody test

Tensilon test → edophonium chloride

155
Q

what test would you run to check for hypercalcemia associated with a lymphoma or thymoma

A

ionized calcium

156
Q

what is the median survival time for animals with mediastinal mass

A

cats ~5 years

dogs > 2 years

157
Q

what is the signalment for a primary lung timor

A

no breed/ sex predilection

usually 11-12 years old

larger breeds

158
Q

what are the main primary lung tumors we see

A

bronchoalveolar carcinoma

adenocarcinoma

these make up over 95% of primary lung tumors

159
Q

describe a partial lung lobectomy

A

removing focal lesions of the peripheral ½ to ⅔ of the lobe

or biopsy

  1. place clamps proximal to the lesion
  2. place 2 continuous overlapping suture patterns proximal to the clamps
  3. excise the tissue
  4. oversew the lung
  5. leak test
160
Q

how would you perform a total lung lobectomy

A
  1. lateral thoracotomy
  2. clamp bronchus near the hilus
  3. isolate the lobe
  4. blunt dissection to isolate the artery w/ 3 suture technique
  5. ligate vein in same way
  6. place 2nd clamp and transect bronchus
  7. continous horizontal mattress and oversew
161
Q

what are some complications of a mediastinal mass lobectomy

A

pneumothorax

hemorrhage

insisional complications

persistent discomfort

162
Q

describe a lung lobe torsion

A

UNCOMMON

young pugs (about 4.5) → left cranial lobe

older, lg breed dogs

males predisposed

cats → around 9

lobar sign on rads

MOST COMMON ON RIGHT MIDDLE AND LEFT CRANIAL

163
Q

where is a lung lobe torsion most likely to occur

A

left cranial or right middle lung lobes

164
Q

how would you treat a lung lobe torsion

A

lung lobectomy WITHOUT DEROTATING IT

prognosis fair to gaurded (50-60%)

pugs are more favorable to live… which is so weird

165
Q

t/f: rib fractures require surgery

A

false

usually conservative management

166
Q

what is flail chest

A

multiple consecutive rib fractures that can cause paradoxical thoracic wall motion

usually not treated

can tx w/ external splints

167
Q

list the 2 primary rib tumors

A

osteosarcoma

chrondrosarcoma

168
Q

how would you do an en bloc excision with chest wall reconstruction for a thoracic wall tumor

A

can excise up to 6 consecutive ribs

up to 8 in cats

169
Q

what is the prognosis for primary thoracic wall tumors

A

chrondrosarc: 1-3 years

osteosarc- 8 mos (surgery+ chemo)

170
Q

describe a pectus excavatum

A

developmental defect of sternum/ caudal ribs

many patients asymptomatic

easier to tx when young

external splinting or internal fixation

171
Q

which breed/ species are predisposed to pectus excavatum

A

burmese and bengal cats

172
Q

what is the most important thing when performing cardiac surgery

A

ATRAUMATIC TISSUE HANDLING AND GOOD SX TECHNIQUE!

173
Q

how would you close after cardiac sx

A

3-0 to 6-0 tiny suture w. taper point (atraumatic)

polyproylene, polytetraflouroethylene, braided polyester

silk for ligatures

174
Q

what is the signalment for a PDA

A

purebreds

females > males

poodles, keeshonds, maltese, bichon frises, yorkies, cocker spaniels, pekingese, collies, shelties, poms, corgis

heritable→ poodles and corgis

hypoplasia & segmental asymmetry of the ductus muscle mass → failure of ductus contraction

175
Q

desceribe the pathophys of a Left → Right PDA

A

***MOST DIE BEFORE 1 YEAR OLD***

aorta → pulmonary artery

left side volume overload

L ventricular and atrial dilation

progressive deterioration

L sided CHF

progressive functional mitral regurge → more overload of left ventricle

A-fib

176
Q

Describe the pathophys of a R → L PDA

A

late development or shortly after birth

pulmonary a→ aorta

suprasystemic pulmonary hypertension → reverses shunt

differential cyanosis → hypoxemia & cyanosis more intense caudally

exercise intolerance, varying hypoxemia, polycythemia

177
Q

how would you diagnose a L→ R PDA

A

cardiac murmur → continuous, left heart base +/- thrill

femoral pulses → bounding or hyperkinetic from low diastolic pressure that causes shunting of blood through ductus during diastole

Thoracic rads

ECG- confirmatory diagnosis

178
Q

what would you see on an ECG with a patient that has a L→ R PDA

A

tall R waves on lead 2

a fib or ventricular ectopy

LA enlargement

LV chamber dilatation

increased aortic ejection velocity

reverse turbulent flow in pulmonary artery on Doppler

179
Q

how would you diagnose a R→ L shunt (PDA)

A

cyanosis (hallmark)→ more severe in caudal mucus membranes; due to postition of ductus in relation to bifurcation of the brachycephalic trunk

femoral pulses are NORMAL

no cardiac murmur

thoracic rads

180
Q

What are the indications for surgery for a L→ R shunt (PDA)

A

ALL CASES BC OF POOR LONG TERM PROGNOSIS W/OUT CORRECTION

exceptions:

surgical ligation (not until 8 weeks but before 16 weeks;

CHF: tx w/ diuretics before surgery (sx 24-48 hours post op)

supresystemic pulm. hypertension

181
Q

what are the indications for surgery to repair and R → L shunt (PDA)

A

DONT DO IT!!!!!!!!!!!!!!!!!

182
Q

how would you perform a L→R shunt (PDA) surgery

A

left 4th intercostal thoracotomy (dogs)

left 4th-5th (cats)

blunt dissection, deep and parallel to the ductus

ligate with 2 sutures using 2-0 silk; place suture closest to aorta 1st

BRANHAM REFLEX: INCREASED BP DECREASED HR

183
Q

what is the branham reflex

A

increased blood pressure

decreased heart rate

184
Q

what are some potential complications after a PDA shunt repair

A

rupture of PDA or great vessels (most severe and most common cause of mortality)

residual flow but rarely hemodynamically significant; another sx not needed

185
Q

describe the general outcome of L→ R shunt sx

A

curative for most cases if performed <6 mos of age

mitral regurge and 2ndary myocardial failure generally reversible post op

low risk of surgical mortality (<7%)

CHF increases risk of post op mortality

186
Q

what is a vascular ring anomaly

A

developmental issue of the great vessels that encirlce the esophagus/ trachea by an incomplete or a complete ring of vessels

embryo: paired dorsal and ventral aortas

6 interconnecting pairs of aortic arches correspond to 6 brachial arteries

187
Q

What breed is most commonly assoc. w/ persistent right aortic arch (PRAA) w/ left ligamentum arteriosum

BONUS: where does it usually occur

A

german shepherds, irish setters

persians or siamese cats

BONUS: usually at right 4th aortic arch

188
Q

what is the most common clinical vascular ring anomaly

A

persistent right aortic arch w. left ligamentum arteriosum

189
Q

when are persistent right aortic arch cases typically diagnosed?

A

between 2-6 mos old

190
Q

what are the c/s of Persistent RIght Aortic Arch

A

usually normal until weaning

postprandial regurge once starting solid food

esophageal obstruction

191
Q

what would you see on p/e for a PRAA pup?

A

malnourished but always hungry

megaesophagus (especially noticebale cranially)

192
Q

where would you cut for a PRAA in a dog

A

left side

4th intercostal thoracotomy

193
Q

Where would you cut for a PRAA in a cat

A

left 4th-5th intercostals

194
Q

what suture would you use for ligation for a PRAA

A

two sutures

2-0 sillk

195
Q

why do you use a stiff balloon for a PRAA

A

breaks down fibrous bands

196
Q

t/f: signs usually resolve after a PRAA

A

true

megaesophagus may not resolve fully

197
Q

what is the most common complication with PRAA surgery

A

persistent regurgitation

→ aspiration pneumonia and death

198
Q

why would you do a pericardiectomy

A

chronic or recurrent pericardial effusion (idiopathic or neoplastic)

or cardiac tamponade

or multiple pericardiocenteses

199
Q

what are the types of a pericardiectomy

A

total → rarely done

subtotal

200
Q

describe the main points of a subtotal pericardiectomy

A

4th-5th intercostal thoracotomy

can be left or right

median sternotomy

fillet= alternative

201
Q

how would you perform a subtotal pericardiectomy

A

cut ventral to the phrenic nerve

incise AROUND caval vessels

retract heart and cut opposite side ventral to phrenic nerve

divide the sternopericardial ligament

202
Q

how would you perform a pericardiectomy thorascopically

A

make a pericardial window → subtotal pericardiectomy

dorsal or lateral recumbency

3 portal technique

window in pericardium ( >3x3 cm)

203
Q

what is the most common cardiac neoplasia

A

right auricular hemangiosarcoma

204
Q

what is the prognosis for a right auricular hemangiosarcoma

A

bad

highly metastatic

sx & chemo→ 6 mos

sx alone → 6 weeks

pericardiectomy alone wont help increase survival

205
Q

how would you resect a right auricular hemangiosarcoma

A

pericardiectomy

mass resection

206
Q

what is the most common aortic body tumor

A

chemodectoma

207
Q

what breeds are more commonly assoc w/ a chemodectoma

A

BRACHYCEPHALICS!!! (boxers, bostons, english bulldogs)

locally invasive

not resectable

208
Q

what happens with a chemodectoma

A

leads to pericardial effusion

MST w/ sx= 22 mos

MST is 4 mos without sx

209
Q

list the most common oral tumors in the dog

A

epulides

malignant melanoma

squamous cell carcinoma

fibrosarcoma

210
Q

list the most common oral tumors in the feline

A

squamous cell carcinoma

fibrosarcoma

211
Q

what are epulides

A

most common benign oral tumor → smooth surfaced nodular gingival mass

originates from periodontal ligament → local excision is curative

if originating from odontogenic epithelium→ acanthomatous ameloblastoma; needs more aggressive dissection; can become malignant; radiation is effective

212
Q

describe melanoma in the oral cavity

A

ALWAYS MALIGNANT

gingiva. buccal/ labial mucosa > palate > tongue

firm brown-black color

amelanotic is usually less differentiated

locally invasive

mets to regional LN’s early on (80% of time)

213
Q

what should you do with a malignant melanoma patient

A

surgery +/- radiation

MST: 8-9 mos

better w/ LN removal and vaccine

AMELANOTIC MELANOMA→ WORSE PROGNOSIS

214
Q

describe a squamous cell carcinoma in the oral cavity

A

usually gingival, tonsils & base of tongue

ulceration is common, red friable mass

prognosis worsens as it is more caudal

gingival: locally invasive but mets later: rostral mass w/ wide resection is possibly curative
tonsilar: very aggressive; nearly alwayw metted at diagnosis and usually not resectable

HAVE TO RESECT W/ WIDE MARGINS AND DO PHOTODYNAMIC THERAPY IF <1CM DEEP

215
Q

Fibrosarcoma oral tumors

A

large breed dogs

usually on maxillary gingiva and hard palate

pink, red, firm, smooth, multi-lobulated masses

locally invasive and aggressive in younger animals

WIDE SURGICAL RESECTION W/ RADIATION THERAPY (LOCAL RECURRENCE COMMON)

216
Q

what is a high-low fibrosarcoma

A

golden retrievers

usually low grade histologivally and come back as benign and inflammatory

BUT THEY ARE BIOLOGICALLY A HIGH GRADE!!!
VERY LOCALLY INVASIVE AND LOW RISK OF METASTASIS

respond to radiation

217
Q

describe a feline oral SCC

A

MOST COMMON ORAL TUMOR IN THE CAT

guarded → poor prognosis

extensive bony involvement

local recurence is common

check FeLV and FIV status

SX, radiation, chemo, photodynamic therapy

218
Q

what are some surgical treatment options for oral tumors

A

debulking

wide resection w. maxillectomy or mandibulectomy

219
Q

what are some advantages of oral surgery

A

ADVANTAGES:

blood supply is huge

saliva is bacteriostatic

heals fast

220
Q

what are some disadvantages with oral surgery

A

contaminated

high motion and high tension

hard to maneuver in

221
Q

what is the blood supply to the maxilla

A

major palantine

minor palantine

222
Q

what is the blood supply to the mandible

A

mandibular alveolar artery

mental arteries

223
Q

what are some ways you can perform a partial maxillectomy

A
  1. hemi
  2. rostral
  3. bilateral rostral
  4. central
  5. caudal
224
Q

how would you perform a partial maxillectomy

A

incise oral mucosa 1 cm beyond mass (2-3 if fibrosarcoma)

seperate soft tissues

save 1 canine tooth if you can

maxillectomy cut

MAKE SURE YOU HAVE A GOOD SEAL FROM THE NASAL CAVITY

labial mucosa-submucosa flap

225
Q

describe the direct apposition technique for an oronasal fistula

A

elevate & mobilize

close mucosa to mucosa

absorbable suture

TENSION→ FAILURE

226
Q

describe the buccal flap technique for an oronasal fistula

A

release mesially and distally

incisions diverge into buccal mucosa

elevate palatal margin

suture corners first

TENSION → FAILURE

227
Q

describe the double flap technique for an oronasal fistula

A

create palatal incisions

elevate

digital pressure on ROSTRAL PALATAL ARTERY

invert

create buccal flap and suture over the palatal flap

228
Q

t/f: a cleft palate revision is usually only performed once

A

FALSE!

MULTIPLE PROCEDURES W. ADEQUATE HEALING TIME IN BETWEEN

229
Q

describe a cleft palate repair

A

repair at 3-4 mos old

after 1st round of shots, stronger mucosal tissues and they are a little bigger so its easier to move around in there

outpatient sx: owner management

multiple procedures with 3 weeks in between

230
Q

how long should you have in between cleft palate surgery

A

3 weeks to allow for adequate healing

231
Q

where should rostral mandibulectomies be?

A

between 2nd and 3rd premolars

TO AVOID CANINE ROOTS

232
Q

DESCRIBE A CHEILOPLASTY

A

total hemimandibulectomy

level of premolar 1 or canines

remove mucocutaneous junction

prevents drooling or tongue hanging out

233
Q

what are the main points of oral surgery?

A

WIDE MARGINS

avoid electrosurgery on oral mucosa

minimal tissue handling

TENSION FREE CLOSURE: best if over bone

appose mucosa

suture w. PDS in subq and monocryl over mucosa (some people like braided vicryl)

234
Q

which veins make up the external jugular

A

lingual facial and maxillary

235
Q

where are salivary mucoceles most commonly located

A

mandibular or sublingual

236
Q

describe the potential locations of a salivary mucocele

A

cervial

sublingual or RANULA

pharyngeal

237
Q

what are the clinical signs of a salivary mucocele

A

swelling (usually not painful)

dysphagia

dyspnea

exopthalmos

238
Q

how do you find the correct gland for a salivary mucocele

A

ask which side came firs

place in dorsal and see where it falls (falls to affected side)

239
Q

T/F: you should NOT repeatedly drain a salivary mucocele because it can lead to an abscess

A

TRUE

240
Q

Describe the procedure for a mandibular or sublingual salivary mucocele

A

incise over mandibular gland

CRANIAL TO CAUDAL

penetrate capsule

blunt and digital dissection rostrally

ligate @ lingual nerve

241
Q

describe the procedure for a ranula or pharyngeal mucocele

A

MARSUPIALIZATION FOR RANULA:

incise the “roof” of the ranula

suture the lining of the ranula (pocket under the tongue) to the sublingual mucosa with monocryl → allows for drainage and heals via 2nd intention

sialoadenectomy later if it recurs

242
Q

where is the most common place for an esophageal foreign body

A

narrowest places:

thoracic inlet

base of heart

diaphragm

243
Q

how would you do surgery to remove a foreign body in the esophagus

A

90% removed via endoscopy

push into stomach and perform gastrotomy

esophagotomy: SUBMUCOSA IS THE HOLDING LAYER→ no serosa and you avoid trauma to the esophageal edges

244
Q

what are the clinical signs and treatment options for an esophageal stricture

A

dysphagia 6 weeks aftger anesthesia/ surgery

tx: balloon catheter dilatation or R&A

245
Q

describe the vascular supply to the cervical portion of the esophagus

A

thyroid and subclavian br

246
Q

describe the thoracic vascular supply to the esophagus

A

bronchoesophageal and aorta br

247
Q

describe the abdominal vascular supply to the esophagus

A

LEFT gastric and phrenic br

248
Q

describe the location of the esophagus

A

cervical and thoracic: LEFT OF MIDLINE

tracheal bifurcation to stomach: RIGHT OF MIDLINE

249
Q

what are some complications of esophageal surgery

A

aspiration pneumonia

esophagitis→ regurge → aspiration

dehiscence → mediastinitis

stricture

250
Q

describe a cervical esophageal surgery

A

ventral midline approach

find recurrent laryngeal n

esophageal stethoscope helps us find it

use gelpi retractors

251
Q

how would you perform an esophagotomy for a foreign body

A

isolate site w/ damp lap pads

suction

stay sutures

incise over or caudal to the foreign body

2 layer closure:

1st layer: intraluminal

2nd layer: extraluminal

252
Q

describe a partial esophagectomy

A

remove 20-50% (3-5cm)

partial (circumferential) myotomy

support or patching techniques

place stay sutures then anastomose with an intraluminal and extraluminal closure

253
Q

what is the arterial blood supply to the lesser curvature

A

left gastric (from celiac)

right gastric (from the hepatic)

254
Q

what is the arterial blood supply to the greater curvature

A

left gastroepiploic (from splenic)

short gastric (from splenic)

right gastroepiploic (from gastroduodenal)

255
Q

what is the holding layer for the esophagus/ stomach?

A

SUBMUCOSA!

256
Q

what foreign bodies must be removed

A

if there is a pyloric outflow obstruction

toxic/ caustic or sharp objects (batteries, pennies minted after 1983)

nondigestible objects

things that are large enough to cause intestinal obstruction

linear foreign bodies

257
Q

what acid-base and electrolyte abnormalities are common in foreign body patients

A

hypokalemia

metabolic ALKALOSIS

258
Q

how would you perform a gastrotomy

A

ventral midline celiotomy

explore abdomen

pack off stomach w/ moistened lap sponges

stay sutures at each end of the planned site (3-0 PDS on a taper needle; full thickness bites)

incise @ ventral body of the stomach between lesser and greater curvatures (less vascular here)

stab incision into the lumen then extend with metzies

remove FB

CLOSURE:

one or two layer

holding layer→ submucosa

continuous or simple interrupted pattern w/ 3-0 PDS (SC in mucosa/ submucosa and cushing or lembert in seromuscularis)

LAVAGE LAVAGE LAVAGE

259
Q

T/F: medical management is the mainstay of treating a gastric ulcer

A

true!

260
Q

when would you take a gastric ulcer patient to sx

A

full-thickness biopsy needed

resection or a deep/ perforated ulcer

intractable bleeding

261
Q

how would you operate on a gastric ulcer

A

local resction of ulcerated tissue

OR

partial gastrectomy:

isolate w/ stay sutures ans Doyen forceps

ligate blood supply

Resect

close w/ TA stapler or 2-layer inverting suture pattern (3-0 PDS simple cont. in mucosa/ submucosa and cushing/ lembert in seromuscularis); holding layer→ submucosa

262
Q

what is the most common gastric neoplasia in dogs

A

adenocarcinoma

263
Q

what is the most common neoplasia in cats

A

lymphoma

264
Q

how would you diagnose gastric neoplasia

A

endoscopy or incisional biopsy

265
Q

how would you surgically treat polyps or benign masses in the stomach

A

submucosa or marginal excision

266
Q

how would you surgically treat stomach cancer that is a solitary, malignant mass

A

wide surgical excision

(partial gastrectomy)

267
Q

how would you surgically treat pyloric involvement of a gastric neoplasia

A

partial gastrectomy w/ pylorectomy

(bilroth 1 or 2)

268
Q

what is a bilroth 1 procedure

A

PYLORECTOMY W/ GASTRODUODEONOSTOMY

so you resect the pylorus and attach the stomach to the duodenum

can be sutured or stapled together

BILIARY DIVERSION USUALLY NOT NEEDED

269
Q

what is a bilroth 2?

A

PYLORECTOMY W/ GASTROJEJUNOSTOMY

so you take out the pylorus and the duodenum and attach the stomach to the jejunum

side-side anastomosis of the jejunum to the stomach (sutured or stapled)

BILIARY RE-ROUTING NECESSARY (CHOLECYSTOJEJUNOSTOMY)

guarded to poor prognosis

270
Q

what are some other names for a benign gastric outflow obstruction

A

pyloric stenosis

chronic antral mucosal hypertrophy

chronic hypertrophic pyloric gastropathy

271
Q

what is the common signalment for a benign gastric outflow obstruction

A

brachycephalics (boxers, bulldogs, bostons)

siamese cats

usually present at a young age

272
Q

what are the clinical signs of a benign gastric outflow obstruction

A

vomiting

regurgitation

273
Q

what diagnostics would you perform for a benign gastric outflow obstruction

A

upper GI series (contrast rads)

gastroduodenoscopy

biopsy (rule out neoplasia or pythiosis

274
Q

how would you surgically correct a benign gastric outflow obstruction

A

Y-U pyloroplasty or Bilroth 1

they provide the widest diameter

good prognosis

275
Q

what are the indications for a gastrostomy tube

A

inappetence

gastric decompression

276
Q

how would you place a gastrostomy tube

A

open or endoscopically

place tube after making a stab incision in the gastric body after purse-strings are placed

LEFT ABDOMINAL WALL GASTROPEXY

LEAVE TUBE IN FOR 14 DAYS FOR THE STOMACH TO MAKE A STOMA; EVEN IF THEY START EATING AT LIKE DAY 2

277
Q

What is the common signalment for a GDV

A

large → giant breeds (great danes, german shepherds, standard poodles)

middle aged or older

great danes can be younger

278
Q

list some possible risk factors for a GDV

A

relative w. history of GDV

deep chested

underweight

rapid eaters

large volume of food SID

heavy exercise right after eating

eating from raised bowls

stress

279
Q

what happens to a GDV patient after the volvulus happens

A

gastric distention is progressive due to cardia and pyloric obstruction

280
Q

what do GDV patients usually present with (history)

A

non-productive retching

anxiety

depression

abdominal distention

281
Q

how would you diagnose a GDV

A

RIGHT LATERAL RADS

POP-EYE ARM/ BOXING GLOVE SHAPE ON RADS

282
Q

Describe the cardiovascular effects on a GDV patient

A
  • increased Intra Abd pressure → decreased venous return → decreased output and decreased splanchnic perfusion
  • hypovolemic shock
  • cardiac arrythmias
    • VPC’s and V-tach
283
Q

what are the respiratory effects on a GDV patient

A
  • decreased tidal volume 2ndary to abd distention
    • hypercapnia leads to metabolic ACIDOSIS
284
Q

what are the gastrointestinal effects on a GDV patient

A

decreased perfusion bc of the distention and volvulus

285
Q

what are the metabolic derangements that happen in a patient with a GDV

A

cellular hypoxia → metabolic acidosis (hyperlactatemia)

free-radical formation and repurfusion injury

endotoxemia

286
Q

how would you treat a GDV patient when they come in shocky

A
  • 2 cephalic IV catheters
  • blood for PCV/ TP, glucose and lactate
    • save some for CBC/Chem
  • shock doses of fluids (90ml/kg crystalloids or 20ml.kg hetastarch)
    • ¼ dose at a time
287
Q

how would you perform gastric decompression for a GDV patient after atabilizing them

A

orogastric tube (w/ heavy sedation or anesthesia!)

gastric trocarization w. a 16 or 18 gauge needle or catheter

288
Q

how would you surgically correct a GDV

A

midline celiotomy

decompress stomach

derotate by pulling the pylorus ventrally and caudally while pushing body of stomach dorsally

explore rest of abdomen

check for necrosis

check the spleen for infarction (artery pulses; it will decrease in size really fast if it is not infarcted)

partial gastrectomy if needed

splenectomy if infarcted

gastropexy (incisional preferred)

289
Q

WHAT ARE THE 4 P’S OF A HEALTHY GUT

A

PINK

PERFUSION

PERISTALSIS

PULSE

NECROSED: gray to black, no peristalsis, thin walled compared to normal and no gastric slip

290
Q

how would you perform an incisional gastropexy

A

5-6cm seromuscular incision in pyloric ANTRUM

5-6 cm incision caudal to the last rib on RIGHT SIDE (through peritoneum and transversus abdominal m)

suture stomach to body wall with 2 continuous lines of 0 or 2-0 PDS or Prolene

SUTURE SEROMUSCULARIS ONLY

291
Q

What are the most common complications of a GDV post op

A

arrythmias

hypotension

DIC
peritonitis (gastric rupture)

sepsis

recurrence (rare if you pexy it correctly)

292
Q

how can you PREVENT a GDV in an at-risk animal

A

prophylactically gastropexy it

open, lap assisted, endoscopic assisted, total lap

can be done at the same time as you neuter them

293
Q

what breeds are pred isposed to a hiatal hernia

A

english bulldogs and shar peis

294
Q

what are the common signs assoc. w/ a hiatal hernia

A

regurgitation mostly

can be vomiting, hypersalivation, dysphagia, resp distress, anorexia, weight loss, hematemesis

some are asymptomatic

295
Q

how would you treat a hiatal hernia

A

herniorrhaphy w/ esophagopexy

avoid the vagal trunks and esophageal vessels

LEFT sided gastropexy

296
Q

which vascular structures provide blood to the spleen

A

short gastric aa

left gastroepiploic aa

splenic aa

297
Q

list some indications for a splenectomy

A

hemoabdomen

splenic mass (hemangiosarcoma, lymphoma, etx)

splenic torsion

immune-mediated dz (not common)

298
Q

list some indications for a partial splenectomy/ incisional biopsy

A

diffuse or focal disease (not a tumor)

trauma

299
Q

what is the most common cause of hemoabdomen

A

splenic hemangiosarcoma

300
Q

how would you perform a splenectomy

A

ligate the splenic hilar vessels→ saves the short gastrics

ligation of splenic artery and vein → HAVE TO PRESERVE THE BRANCHES TO THE PANCREAS but not the short gastric a & left gastroepiploic a.

301
Q

how would you perform a partial splenectomy and what is the most common reason for doing it?

A

ligate hilar vessels, place mattress sutures in the splenic parenchyma

TRAUMA NOT FOR TUMORS

302
Q

What are some common complications with splenic surgery

A

hemorrhage

arrythmias (VPC’s, V-tach)

GDV→ reported as early as 5 days to 6 mos postop; gastropexy at risk puppers

303
Q

describe the afferent blood supply to the liver

A

portal vein provides 80% → drains stomach, intestines, pancreas, spleen

arterial system provides 20% (hepatic a) →branch of the celiac artery

304
Q

describe the efferent blood supply to the liver

A

hepatic veins

caudal vena cava

305
Q

describe hepatic insufficiency

A

>70-80% loss of hepatocytes

  • decr protein synthesis
  • hypoglycemia
  • incomplete or delayed detoxification
  • decr. drug clearance
  • incr. coag times (PT/PTT)
306
Q

what are some indications for hepatic sx

A

diffuse hepatic dz → incisional biopsy

focal hepatic dz → incisional biopsy, liver lobectomy, partial lobectomy

vascular abnormalities → PSS

307
Q

list some indications for a liver lobectomy

A

hepatic neoplasia

hepatic abscess

liver lobe torsion

hepatic trauma

308
Q

what are the most common forms of hepatic neoplasia in the dog

A

hepatocellular carcinoma

massive→ good prognosis

nodular/ diffuse → poor prognosis

Bile duct carcinoma

very bad

309
Q

what is the most common form of hepatic neoplasia in the cat

A

benign tumors more common:

hepatocellular adenoma

hepatobiliary cystadenoma

SX TYPICALLY CURATIVE

310
Q

describe hepatic sx for a liver abscess

A

hepatic abscesses are rare

lobectomy indicated for solitary abscesses

guarded prognosis

disemminated → very very poor prognosis

311
Q

describe a hepatic lobar torsion

A

RARE

large breeds

non-specific signs

dx: ultrasound

tx: lobectomy without untwisting the necrosed lobe

good prognosis

312
Q

would you take a patient w/ hepatic trauma to surgery?

A

not usually → can usually control w/ supportive care

unless there is uncontrollable hemorrhage or biliary leakage

313
Q

list some tests you would run before liver surgery

A

minimum database (CBC/Chem/ UA)

coagulation profile

bile acids

ammonia tolerance test

314
Q

how much of the liver can you remove at one time

A

< or equal to 70%

hepatic insufficiency can happen if you take more than this

315
Q

incisional liver biopsy

A

indicated for diagnosis of diffuse hepatic dz

cholangiohepatitis, fibrotic liver dz, diffuse neoplasia, microvascular dysplasia

non surgical- tru-cut biopsy w/ US guidance

surgical: laparotomy (guillotine, wedge, punch biopsy) or laparoscopy

316
Q

partial liver lobectomy

A

peripheral lesions, masses

methods: fracture method (incise capsule→ crush overlying parenchyma, and ligate large and cauterize small vessels, overlapping sutures, staples

317
Q

complete liver lobectomy

A

“hilar resection”

for masses at or near the hilus

ligate arterial, venous, portal and biliary supply at the hilus

technically more challenging

more complete resection

better hemorrhage control

318
Q

stapling method for liver surgery

A

partial and complete liver lobectomy

TA stapler (55 or 90mm)

319
Q

what are some complications of liver surgery

A

hemorrhage

recurrence

cardiac arrythmias (large mass)

320
Q

describe the flow of bile

A

liver canaliculi→ interlobular ducts → lobular ducts → hepatic ducts → Gallbladder via cystic duct → common bile duct → bile salts reabsorbed in ileum and transported back to the liver

321
Q

what is the purpose of bile? What is excretion stimulated by?

A

fat emulsification

stimulated by:

cholecystokinin, motilin and cholinergic pathway

322
Q

list some indications for extrahepatic biliary sx

A

biliary obstruction

  • GB mucoceole
  • tumor
  • stricture (trauma)
  • 2ndary to pancreatic swelling

biliary rupture

  • bile peritonitis

neoplasia

323
Q

list c/s of biliary obstruction

A

icterus (cholestasis; serum bili >1.5-2)

324
Q

t/f: a bile duct r&a is commonly performed

A

FALSE

not unless there is severe dilatation

325
Q

describe a cholecystectomy

A

indicated for: trauma, neoplasia, cholecystitis, obstruction, biliary mucocoele, cholelithiasis (very rare)

free the GB from the hepatic fossa, ligate the cystic duct above the hepatic duct

326
Q

describe biliary diversion sx

A

cholecystoduodenostomy (Bilroth 1)

cholecystojejunostomy (bilroth 2)

indicated for: common bile duct obstruction; GB HAS TO BE FREE OF DISEASE

free GB from fossa, appose to guts, make a 3-4cm stoma, then 1 or 2 layer closure

327
Q

what are some complications and the prognosis for the following extrahepatic biliary surgeries: cholecohotomy, bile duct R&A, or biliary stenting

A

complications: dehiscence, septic bile peritonitis (usually fatal >50%)
prognosis: high mortality (20-30%). high morbidity

328
Q

what is the basic definition of a portosystemic shunt

A

an anomalous vessel that allows portal blood to bypass the liver

329
Q

what are the 2 main types of extrahepatic shunts

A

portocaval

portoazygos

330
Q

which breeds are most commonly associated with an EXTRAHEPATIC PSS

A

small breeds

yorkies, maltese, shih-tzus

331
Q

what is the most common breed of dog that gets INTRAHEPATIC PSS

A

large breeds

Irish wolfhounds, goldens, australian cattle dogs

332
Q

what is the gender and age predisposition of PSS patients

A

no gender predisposition

usually <1 year old

portoazygos usually present older

333
Q

what is the most common history of a PSS dog

A

failure to grow, anorexia, depression

neuro signs: hepatic encephalopathy (ataxia, stupor, head pressing, circling, seizures/coma); worse after meals

urinary signs: PU/PD, hematuria, stranguria, urinary obstruction, cystoliths (ammonium biurate, radiolucent)

GI signs: vomiting, diarrhea

334
Q

what are the common signs of a cat with a PSS

A

ptyalism (drooling)\

blindness

aggression/ behavior changes

Hep. encephalopathy

copper colored irises

335
Q

t/f: a PSS dog on PE will usually have enlarged kidneys due to increased GFR

A

true

336
Q

what will you see on bloodwork with a dog with a PSS

A

increased ALT, AST, ALP

hypoproteinemia

hypoalbuminemia

low BUN

hypoglycemia

microcytosis w/ normochromic anemia

coag is usually normal

liver fxn: increased ammonia & increased Bile Acids (don’t do if bili is high)

337
Q

describe portal scintigraphy for a PSS

A

minimally or non-invasive

only need sedation

enema- TC99

trans-splenic

hard to tell different types of shunts apart

338
Q

list some advatages and disadvantages of portal scintigrpahy

A

Advantages:

  • non-invasive
  • very and specific

disadvantages:

  • isolation bc of radioactive substances
  • surgery- wait time after scan
    • 60 hours → transcolic
    • 1 hour→ trans-splenic
339
Q

what is the gold standard of diagnosing a PSS with diagnostic imaging

A

CT ANGIOGRAPHY

340
Q

Why is a CT Angiogram the gold standard of diagnosing a PSS

A

non-invasive

allows for accurate localization of intra/extra hepatic shunts!

341
Q

describe pre-op management of a PSS patient

A

stabilize

manage medically for 2-4 weeks before sx:

low protein diet

lactulose→ acidifies colon and traps ammonium; cathartic → increases GI motility and trapped ammonium gets out the body faster; CAN GIVE AS AN ENEMA FOR AN EMERGENCY

antibiotics (Neomycin, metronidazole or ampicillin) → decreases ammonium producing bacteria and decreases absorption of those toxins

anticonvulsants (keppra)→ may help decrease risk of post-attenuation seizures/ decrease severity of them if they do happen; 20mg/kg PO Q8

342
Q

describe how a PSS would be performed

A

ventral midline celiotomy

abdominal exploratory (small liver, large kidneys, bladder stones, find shunt)

ligate the shunt

liver biopsy

343
Q

how do you identify a PSS in surgery

A

left and right gutters:

epiploic foramen: portal vein ventral, caudal vena cava dorsal, hepatic artery is usually pulsing→ MOST SHUNTS ENTER HERE

omental bursa → LEFT SIDE OF STOMACH

cranial to the liver→ PORTOAZYGOS SHUNT

ANY VESSEL CRANIAL TO THE PHRENICOABDOMINAL VEINS IS ABNORMAL

SHUNTS ENTER IN AT RIGHT VENTRICLES AND THERE IS ALWAYS TURBULENT FLOW

344
Q

How would you attenuate an extrahepatic shunt

A

attenuation: ameroid constrictor, cellophane banding or gradual occlusion (decr. risk or portal hypertension and decr. risk of multiple acquired shunts)
ligation: silk suture, acute ligation (complete may be possible, portal hypertension/ multiple acquired shunts may be possible)

345
Q

what is an ameroid constrictor and how does it work for a PSS

A

outer: stainless steel ring
inner: casein ring

stainless steel key

casein will swell and lead to fibrosis (inflammatory reaction) and thrombosis

takes 2-5 weeks for occlusion (faster if thrombosis happens); may not be complete

346
Q

what is cellophane banding and how does it work for a PSS

A

cellulose NOT POLYPROPYLENE

leads to an inflammatory rxn (fibrosis) and thrombosis

time to occlusion: 4-6 weeks; may not be completely occluded

347
Q

describe a silk ligation for a PSS

A

partial or complete ligation

MUST MONITOR PORTAL PRESSURES→ DETERMINES AMOUNT OF CLOSURE

2ND SX MAY BE NEEDED

348
Q

describe intrahepatic shunt ligation

A

harder to identify→ feel liver lobes and there is a soft spot

procedure depends on location:

left lobe: ligate left hepatic vein

right and central: ligate supplying portal vein branch; sometimes can dissect and attenuate shunt

some cannot be attenuated → abnormal development of portal system

349
Q

list some methods for intrahepatic shunt ligation

A

suture ligation (partial or complete), ameroid constrictor, cellophane band, thrombogenic coil placement

350
Q

what are some intra-op complications of a PSS

A

hemorrhage

portal hypertension

misidentification of the shunting vessel

anesthesia → poor/ prolonged drug metabolism

351
Q

what are some post-op considerations after a PSS

A

portal hypertension → higher likelihood w/ acute ligation

H.E. → will continue until shunt attenuated

seizures (status epilepticus) → propofol CRI; Keppra IV

hemorrhage

persistent shunting

acquired multiple extrahepatic shunts

352
Q

why does portal hypertension occur and what are some intraoperative & postop signs during PSS sx?

A

back up of pressure in the portal vasculature

intraop:

hyperperfusion of mesenteric and intestinal vessels; marked increase in GI motility, +/- signs of hypovolemic shock

Postop:

abd. pain, abd distention, bloody vomit/ diarrhea, hypovolemic shock

353
Q

what do you do after a PSS sx for follow up

A

continue med management after surgery while the shunt gets attenuated→ until b/w is normal; min. of 2-4 mos to the rest of their life

serial b/w:

start 2-3 mos postop if doing well

serum chem

bile acids (pre and post)

354
Q

what is the prognosis for extrahepatic and intrahepatic PSS after sx

A

extra: 94% good→ excellent
intra: 60% 1 yr survival

355
Q

what is the cause of multiple acquired shunts

A

chronic portal hypertension (chronic liver dz; arteriovenous malformations; shunt attenuation/ ligation)

vestigial fetal vessels: multiple, tortuous, extrahepatic; connect portal system to the renal veins or caudal vena cava near the kidneys

356
Q

what is the prognosis and surgical procedure for multiple acquired shunts?

A

DO NOT DO SURGERY!!!!!! (CONTRAINDICATED BC VESSELS ARE RELIEVING PORTAL PRESSURE)

poor prognosis w/ liver dz

may be asymptomatic if 2ndary to PSS attenuation

medical management: low protein diet, lactulose, antibiotics

357
Q

describe the prognosis in cats w/ PSS

A

higher complication rate (up to 77%)

neuro complications common (blindness/ seizures)

prognosis: up to 75-80% have excellent outcome

358
Q

describe microvascular dysplasia

A

“portal vein hypoplasia- microvascular dysplasia” (PVH-MVD)

typically no portal hypertension

small intrahepatic portal veins → microvascular shunts in the liver

breeds: cairn terriers and yorkies

359
Q

which breeds are predisposed to microvascular dysplasia

A

cairn terriers and yorkies

360
Q

describe the signs of microvascular dysplasia with PSS or alone

A

w/ PSS:

often have concurrent MVD
NEED LIFELONG MEDICAL MANAGEMENT

MVD alone:

present older in life

less severe c/s

better long term prognosis w/ med management

361
Q

describe c/s, work up and treatment for microvascular dysplasia

A

C/S:

similar to PSS

maybe less severe

work up:

similar to PSS

no shunt found

liver biopsy→ findings similar to PSS

tx:

medical management like w/ PSS

362
Q

how do you diagnose a septic abdomen

A

intracellular bacteria on abdominocentesis

363
Q

when should you never use barium for rads?

A

IF YOU SUSPECT A PERF!

364
Q

what are the principles of SI SX

A

early dx and good techniques prevent most complications

perform sx asap after dx for perforation, strangulation, obstruction

approximating suture patterns→ simple interrupted, simple continuous, monofilament, absorbable suture (PDS)

SUBMUCOSA ENGAGED in all sutures (submucosa is holding layer)

non-traumatic forceps (Doyens) or fingers to prevent leakage

debakey forceps (less traumatic than Brown-Adson’s or Rat tooths)→ do not pinch the tissue with these!

cover sx sites w/ omentum or serosal patch

replace contaminated instruments and gloves before closing

local lavage of anastomosis

perioperative abx

optimal healing→ good blood supply, mucosal apposition, minimal trauma

365
Q

which factors delay healing and increase the risk of dehiscence for Small intesinal SX

A

hypovolemia

shock

HYPOPROTEINEMIA

debilitation

infection

366
Q

list some indications for an enterotomy

A

FB
full thickness biopsy

longitudinal incision

longitudinal vs. transverse closure: transverse usually not needed; only for teeny tiny patients

leak test

wrap omentum (patch)

complete exploratory→ mesenteric border

367
Q

describe a serosal patch

A

uses ANTI-mesenteric borders

loose loop of intestines

avoid sharp bends

368
Q

how much small intestine can you remove during surgery

A

up to 70-80% without complication

short bowel syndrome: proximal resection is better than distal

369
Q

how would you perform a small intestine R&A

A

equal diameter→ 60-90 degree incision→ MESENTERIC SIDE LONGER

unequal diameter→ 45-60 degree incision

tapered needles

3-0 to 4-0 suture

can use simple interrupted or 2 lines of simple continuous with 50% of circumference each

mesenteric suture line placed 1st (hardest to place and the first to leak)

close the mesenteric rent→ avoid damaging blood supply to the remaining bowel

370
Q

what is a radiogaphic dx of a small intestinal FB

A

SI loops greater than 1.6-2X the height of the body of L5

371
Q

when should you not do a FB surgery

A

if its in the colon

stomach→ can possibly do endoscopy

progressive movement w/ serial rads

partial obstruction

372
Q

when should you take a FB dog to sx

A

severe vomiting/ dehydration

debiliatated

suspect peritonitis

complete obstruction/ markedly distended bowel (rupture risk)

linear FB

failure to pass in 36 hours

no movement on serial rads in 8 hours

373
Q

what electrolyte and metabolic abnormalities do you expect with a FB

A

hypokalemia

metabolic alkalosis

SA Surgery (1 decks)

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