Soft tissue surgery Flashcards
What is a pinnectomy?
removal of tip of ear. indications:trauma, neoplasia (SCC, MCT, MM), necrosis. Total pinnectomy for SCC - good prognosis with complete excision. total Pinnectomy performed to obtain adequate margins.
Describe an aural haematoma and how it is treated
Cartilage usually split, trauma implicated, usually otitis externa. Requirements of therapy - drainage, limit scarring, prevent recurrence. Can treat with centesis +/- corticosteroids. eg 0.2% dexamethasone diluted 1:10 ins aline. Incisional drainage - sigmoid over linear incisions. Incisional drainage - appositional suture pattern spaced <1cm apart without stents. Penrose drain placement - through and through, bandage after.
What is the aim of a lateral ear canal resection?
Provide direct entry to horizontal ear canal, improve local environment, facilitate medication. LECR does not cure ear disease. Indications: mild recurrent otitis externa, lesions on lateral wall of vertical canal, advanced otitis externa/media. LECR drainage board - cerumen produced at base of canal moves up to opening, moves onto baffle plate, dries and falls off.
What is a total ear canal ablation with lateral bulla osteotomy?
TECA - LBO - remove ear canal + curette middle ear. treat otitis externa/media. indications: chronic otitis externa, recurrent otitis media, failed LECR, end stage ear disease, neoplasia, para aural abscesstation, ear canal avulsion. When ear canal ocluded in end stage otitis externa media, the ruptured tympanic membrane or bulging tympanic membrane, occluded horizontal ear canal, bulla opacification, thickening of bulla wall,
What are the potential complications with TECA and LBO?
Retroglenoid haemorrhage, facial nerve damage - exposure conjunctivitis, lose palpebral reflex, drooping lip & ear, drop food from mouth, drool. Vestibular disease - lose balance on one side, nystagmus, positional strabismus, head tilt, vestibular ataxia. Horners syndrome - ptosis, third eyelid protrusion, miosis, enopthalmosis. Deafness, altered ear carriage. Para aural abscess, para aural sinus tract, pain and local swelling, leave epithelial lining to middle ear.
What are the indications for a ventral bulla osteotomy?
Isolated otitis media - common in cats, rare in dogs.
Management of nasopharyngeal polyps. Complications include horners syndrome, vestibular disease, hypoglossal nerve paralysis,
What are the ddx for middle ear polyps? What is the management?
chronic otitis media, middle ear neoplasia, nasopharyngeal neoplasia. Diagnosis: middle ear changes, nasopharyngeal mass, absence of signs of malignancy, histopathology. 1. traction - may combine with LECR for exposure. horners syndrome in 43%. 2. bulla osteotomy + TECA.
What is the difference between the terms celiotomy and laparotomy
celiotomy- any incision into abdominal cavity.
Laparotomy - incision through muscle into abdomen, generally flank incision.
What is acute abdomen?
Catastrophic abdominal pathology - shock,death, early surgical intervention needed.
Describe the anatomy of the layers of the abdomen
3 Lateral muscles, rectus abdominus.
Aponeuroses - internal rectus sheat, external rectus sheath.
Linea alba, peritoneum
Which structures can you access from a paracostal laparotomy?
Liver, stomach, adrenal
When should a ventral midline coeliotomy inciision be made?
OVariohysterectomy
Liver biopsy
Intestinal obstruction.
Organ centred approach (quicker, lower morbidity) or full exploratory coeliotomy. (better exposure, more likely to achieve goal, evaluate entire abdomen.) Always clip for full abdominal surgery, mid sternum to beyond pubis to flank folds. Maximise exposure - excise falciform fat. Watch out for cranial preputial muscle, branches of caudal superficial epigastric artery and vein. Prevent tissues from dessicating with moistened swabs, lavage saline, suction. maximise exposure with abdominal retractors. count swabs in and out.
What can be found in the cranial quadrant of the abdomen?
Diaphragm, liver, gall bladder, stomach.
What can be seen in the right gutter of the abdomen
right limb of pancreas, kidney, adrenal, portal vein, vena cava, ureter, ovary.
what can be seen in the left gutter of the abdomen?
Kidney, ureter, ovary, adrenal
What can be seen in the caudal quadrant of the abdomen
Colon, reproductive tract, bladder, urethra, prostate, inguinal rings.
How do you close coeliotomy?
Layer 1 - linea alba External rectus sheath is the main holding layer use simple interrupted or continuous patterns, monofilament synthetic suture material. 7 throws to start and finish. Layer 2- subcutaneous tissues. Close dead space, supports skin closure. Layer 3: skin apposition
What are the complications of inadequate wound closure?
Incisional hernia, abdominal organs move subutaneously. skin incision dehisces, peritonitis, evisceration, death.
What is peritonitis?
Inflammation of the peritoneum.
primary generalized peritonitis; spontaneous, no pre existiing abdominal disease. eg FIP.
Secondary generalised peritonitis - secondary to pre existing abdominal pathology. examples: rupture of GIT, urine leakage, penetrating trauma, bile leakage following trauma. infectious - bacteria, leakage, often iatrogenic. non infectious - urine, bile, foreign body, pancreatitis. Signs - history of surgery of FB, dullness, abdominal distension, abdominal pain, fluid thrill. Prolonged CRT, palor, tachycardia, weak pulses as signs of shock, signs of sepsis - p yrexia, bounding pulses, toxic mucous membranes. Diagnose with paracentesis and fluid analysis, 4 quadrant tap, or ultrasound guided tap. Loss of serosal detail on radiography. free abdominal gas, turbid abdominal fluid, identification of underlying pathology. manage shock and treat sepsis, address pathology, lavage abdomen, place drains.
What are the normal openings in the diaphragm?
The caval foramen, the oesophageal hiatus, the aortic hiatus.
How do Diaphragmatic hernias occur?
Trauma - 85% - high impact, increase abdominal pressure/open glottis, organ herniation at presentation is common.
Unknown - 10%
Congenital - 5%
Screening warranted for any patient following known trauma eg RTA, falls, with respiratory signs following trauma. 10% of cases do not have witnessed trauma so patients may present with chronic hernias.
What are the signs of diaphragmatic hernia?
Dyspnoea & orthopnoea, gastro intestinal signs, dull on percussion, muffled heart, auscultation of gut sounds in thorax, shock, external signs of trauma,
What will be seen on radiography with diaphragmatic hernia?
Plain - DV not VD, inflated lung p on lateral
Contrast - upper gastro intestinal, positive peritoneography
Loss of diaphragmatic and cardiac contours: pleural effusion/herniated organs.
Displacement of abdominal organs - stomach: apparent microhepatica, abdominal organ loss.
Gas or ingesta filled visci in thorax
When should surgery be done for diaphragmatic hernia?
Immediate surgery - 35% mortality,
After stabilisation - 10% mortality
Delay surgery to stabilise patient perform surgery as soon as patient is stable. manage other injuries after hernia repair. Stabilise with cage rest, fluid therapy, oxygen, analgesia, thoracocentesis. Indications for immediate surgery include - deterioration despite supportive care, intrathoracic GDV, ongoing haemorrhage.
Describe the surgical approach for diaphragmatic hernia?
Ventral midline coeliotomy, pack off abdominal organs, gentle traction on cranial abdominal viscera, tilt table - head up. Location is most frequency - unilateral, ventral, costal. but dorsal easily missed, may be multiple hernias. To reduce contents: GI tract - gentle traction, parenchymatous organs - lift rather than pull: avoid avulsion, do not de rotate immediately. Enlarge hernia ring: extend radial and ventral, decompress hollow organs, gently disrupt adhesions,
How do you suture the defect in the diaphragm?
Simple interrupted or continuous, dorsal to ventral, radial component first, no tension.
How do you re establish negative pressure in the diaphragm?
Forced re expansion highly dangerous. needle thoracocentesis through diaphragm. Place thoracostomy tube if concerned over ongoing pleural disease. Complications: respiratory crisis, pleural effusion reforming, pneumothorax - previous injuries or thoracostomy tube, re expansion of pulmonary oedema,
What is re expansion of pulmonary oedema?
Alveolar flooding after lung re expansion, aetiology uncertain ? barotrauma, linked to forced re expansion of lung, fatal.
What are circumferential costal tears and how do you manage them?
Avulsion from the costal arch, shredding of costal muscle remnant. Management: anchor around costal cartilages & rib, anchor to abdominal body wall.
What are chronic hernias?
Large defects, empty abdomen syndrome, intrathoracic adhesions- may require sternotomy. consider referral.
Describe peritoneo-pericardial diaphragmatic hernias?
Congenital defects, pericardial & peritoneal cavities communicate, often not identified before adulthood. Often clinically silent, or have GI signs. rarely: cardiac tamponade, liver lobe tosion. Concurrent abnormalities may be present as well - cranial abdominal hernias, swirling hair pattern over sternum, fusion defects of sternum,
What may cause a closed traumatic pneumothorax?
Most common type
Fractured rib, or blunt trauma with closed glottis.
Other types: open pneumothorax, tension pneumothorax
What is a spontaneous pneumothorax?
Non traumatic leakage eg pulmonary cysts + blebs, abscess, neoplasia, severe pneumonia.
Management: intermittent thoracocentesis, thoracostomy tube placement for intermittent or continuous drainage (for tension pneumothorax) or surgery, Majority of traumatic pneumothorax cases seal within 72 hours.
When/ how can pneumothorax be treated with surgery?
Surgery - median sternotomy, intercostal thoracotomy.
Indications - not resolving after 72 hours, spontaneous pneumothorax,
What is adrenalectomy?
Surgical removal of one or both adrenal glands. Done for cushings disease, phaeochromocytoma. risk of exsanguination, thrombo embolic disorders, recurrence or metastases, intra operative death, post op addisonian crisis. Rarely done in first opinion practice.
What is a partial pancreatectomy?
Surgical removal of part of the pancreas. Pancreatic biopsy - rarely performed but simple. insulinoma resection - 95% have metastasised, palliative only, requires evaluation of entire pancreas, requires careful peri operative management. concern over pancreatitis, concern over biliary tree damage, concern over loss of duodenal blood supply.
What is a thyroidectomy?
Surgical removal of the thyroid gland. indications - feline hyperthyroidism, neoplasia. A modified extracapsular thyroidectomy removes thyroid & preserves cranial parathyroid. Low recurrence rate. lower hypoparathyrodism rate. Complications: recurrence, laryngeal paralysis, hypocalcaemia (hypoparathyroidism), hypothyroidism. With hypoparathyroidism - most cases occur within 1-4 days, life threatening seizures and dysrhythmias, weakness, tremors, dullness, facial rubbing, panting, anorexia. calcium & vitamin D supplementation. Prognosis with unilateral thyroidectomy - 70% recurrence, bilateral thyroidectomy 5-11% recurrence.
What is the difference between gastrotomy, gastrectomy and gastrostomy?
Gastrotomy: incising
Gastrectomy: excising a portion
Gastrostomy: creating a stoma usually using a tube.
Gastropexy: fixing stomach to body wall
What are the risks with Gastrointestinal surgery? How can these risks be minimised?
Intra operative contamination - isolate from rest of abdomen with swabs or laparotomy pa, use stay sutures, babcock forceps, packing around site in abdominal cavity. Occlude stomach on either side of incision, stay sutures to tent incision up away from pool of fluid in stomach. Lavage and suction to remove spillage.
Post operative dehiscence and leakage - reduce risk of dehiscence with atraumatic tissue handling, use a serosal seal (wrapping serosa around incision site encourages an early water tight seal), or an omental warp. The submucosa is the holding layer use a swaged on cutting needle, use monofilament, synthetic, absorbable, use non crushing patterns. In stomach and colon as alternatives- use double layered, inverting.
Peritonitis
Iatrogenic blockage
What are the signs of gastric disease?
Vomiting , haematemesis, malaenia, dehydration, hypokalaemia, loss of appetite, weight loss.
Why do we starve patients prior to any general anaesthetic?
Reflux of gastric contents into oesphagus
Reflux oesophagitis, aspiration pneumonia
Many patients are starved for 24 Hours following 24 hours after GI surgery to reduce the risk of leakage, but in reality it is unlikely to make any difference.
How does anatomy affect surgery of the stomach?
There is a large collateral blood supply. the submucosa with mucosa separate easily from seromuscular layers.
What are the main indications for gastrotomy?
Foreign body removal, biopsy
Both gastrectomy and gastrostomy are based around the basic technique of gastrotomy. Expose the stomach, Pick avascular area away from the pylorus, Place stay sutures on either side of site, tent stomach up and isolate with swabs, Make stab incision with no 11 scalpel, extent with scalpel or metzenbaum scissors, Close site in one or two layers. incorporate submucosa in at least one layer of sutures. lavage site, suction and remove contaminated swabs.
What do gastric foreign bodies cause?
Obstruction, perforation, poisoning, May gastric FBs are incidental findings. signs may be intermittent if FB sits in body. pyloric obstruction can cause rapid deterioration and dramatic clinical signs. Foreign bodies often move into the intestine between diagnosis and surgery. beware there may be other reasons for vomiting. full exploratory coeliotomy. May show up on radiography if radio opaque FB. On radiography there will be gastric distension - normal fundus 6 icsp suspect pathology. Use contrast to delineate FB.
What is treatment of a gastric foreign body
- Endoscopic removal
2. Gastrotomy
What is gastric dilatation and volvulus sydrome?
An acute life threatening disease characterised by rapid accumulation of gas and air int he stomach which increases pressure within the stomach, resulting in malposition of the stomach and shock. Stomach distends and rotates. dyspnoea and profound shock develop rapidly. Gastric necrosis & perforation follow. Stomach dilates with gas - aerophagia, bacterial proliferation, failure to eructate or to pass gas into intestine, Fills with fluid -food and gastric secretion, transudate from mural venous congestion, blood and mucosal slough as stomach necrosis develops. Usually clockwise rotation, 90 to 360 degrees. pylorus moves ventrally & to left. fundus moves right. The spleen displaces to right dorsal - gastroplenic ligament. congestion:stretching of splenic vessels. ischaemia : infarction or ischaemia of vessels. Intra gastric pressure increases, venous then arterial compression: venous congestion - transudation of fluid, mucosal hypoxia leads to tissue ischaemia, ultimately gastric wall necrosis and erforation. Reduced venous return to the heart, reduced circulating blood volume, cardiac arrhthmias. Diaphragmatic compression. GDV syndrome - acute abdominal crisis, recurrent gastric dilatation, chronic gastric torsion. Intrinsic risk factors: breed, conformation, genetics. Extrinsic risk factors: Diet, husbandry. Predominantly in large breed dogs - gordon stter, irish setter, poodle, Great Dane, weimeraner, St. Bernard. in some bassetts. Deep chested dogs. Diet - single source diet & once daily feeding, processed dry (ceral or soya based) but no single diet has been shown to reduce risk of developing gdv. commonest > 7 yo. 80% recurrence rate if previous episode. Presentation: rapid onset persistent vomiting fluid, tympanic abdomen, collapse. On radiography - cannot identify pylorus on right lateral, fundus distended. > 6icsp.
How is GDV treated?
Stabilisation must start immediately. 1. fluid resuscitation 2. gastric decompression. Derorotation is less important than decompression for preserving gastric wall. Stabilisation with fluid resuscitation at shock doses, crystalloids, colloids. Decompression with orogastric intubation with a lubricated, soft, large bore tube, premeasured to last rib, gag tied in place. or percutaneous decompression (paracentesis). Give IV antibiotics, oxygen therapy, therapy for arrhythmias, analgesia. Delayed intervention risks include gastric necrosis, perforation. Decompress and reposition stomach. 180 degrees clockwise rotation most common, check cardia & pylorus. assess stomach and spleen for necrosis- not viable- wall thinning, green, grey, black. compromised - avulsed vessels, red haemorrhagic. viable - active haemorrhage from nick, pulse, peristalsis. Partial gastrectomy: non viable areas. gastric wall invagination: questionable areas. inverting suture pattern, non viable sloughs. Splenectomy is rarely necessary. consider of persistent congestion after 10 mins of repositioning, avulsion or infarction of vessels, gross necrosis. Prevent recurrence with an incisional gastropexy - right sided antrum anchored to body wall. this prevents pylorus moving, incise seromuscular layer of pylorus and transverse abdominus muscle, suture incision edges together.
What are the complications of GDV?
Early post op - cardiac arrhythmias, gastric wall necrosis, peritonitis. longer term: gastric hypomotility, recurrence 5-10%.
Prognosis with gastric necrosis - 66% survival.
Gastric wall intact - 90-95% survival.
Consider elective gastropexy in high risk cases. restrict excercise before and after feeding & avoid single large feeds.
When is a tube gastrostomy placed?
Tube in pylorus - gastropexy for GDV
Tube in fundus - stomach tube for feeding
Cranial midline coelitomy, pull tube through tunnel in left body wall Feed tube into gastric lumen, make purse string sutures . Place pexy sutures. Secure tube to body wall with a chinese finger tap suture. Prevent patient from removing tube. Introduce feeding gradually over 72 hours. maintain tube for a minimum of 7 days to encourage adhesion formation. early removal risks peritonitis. Tube is removed by traction and site is left to heal by second intention.
What is a hernia?
Protrusion of a structure through a defect in the wall of its normal anatomical cavity. May be umbilical, inguinal, scrotal, femoral or perineal - often congenital or acquired degenerative,less commonly traumatic. Internal abdominal hernias and external abdominal hernias are often traumatic.
What is external and internal abdominal hernia?
External - Usually traumatic, herniation of organ out of abdomen through a defect in the abdominal wall. e.g paracostal hernia, prepubic: avulsion of cranial prepubic tendon, usually RTA, often associated pelvic fractures.
Internal - usually traumatic, herniation of abdominal organs through a ring/defect confined within the abdomen or thorax e.g diaphragmatic hernia
Describe a true hernia, why is this different to a ‘false’ hernia?
Congenital or acquired degenerative. contents within outpouching of peritoneum. Has a hernial sac.
False hernia - usually traumatic, contents are not restrained by a hernia sac.
Which hernias herniate through a natural abdominal opening?
Inguinal, scrotal, femoral - vital structures run through these
Umbilica, internal abdomina, external abdominal - do not herniate through normal body cavity opening.
Describe an umbilical hernia?
Usually congenital - often closed during elective neutering. foetal umbilical rings fail to close. Umbilical hernia is a true hernia.
What are the physical findings in an external abdominal hernia?
Asymmetry of body contour, palpable organs in subcutaneous location, hernia ring (body wall defect). Other clinical signs depend largely on the organs that have herniated, how herniation affects their function, the health of herniated organs. Use radiography/ultrasound. The contents may be reducible, non reducible, incarcerated, strangulated. In strangulated contents the organ blood supply is compromised - distension, torsion, constriction.
How is a hernia repaired?
Access hernia by direct approach or midline coeliotomy. Assess health of contents and take appropriate action e.g remove portion of bowel. Reducing contents may necessitate enlarging hernia ring. Ensure debride devitalised tissue in traumatic hernias. Repair hernia defect. Usually direct apposition of muscle edges. Difficult repairs - large defects; lead to tension on suture line, tension leads to dehiscence. tension free repair must be achieved. May use surgical meshes for repair such a polyproylene. If the body wall is avulsed - anchor around ribs, anchor through bone tunnels.
What are inguinal hernias?
Herniation through inguinal canal. contents adjacent to vaginal process. may be congenital or acquired. may be unilateral or bilateral. sex hormones, pregnancy and obesity may play a role in acquired hernias. Midline incision and dissect over hernia. consider coeliotomy if cannot reduce easily. avoid damaging externnal pudendal vessels. Advise neutering - may reduce recurrence, makes repair in male dogs easier.
What is a scrotal hernia?
Rare, unilateral, organs herniate beside testicular vessels and ductus deferens into scrotum. organ strangulation is common. Castrate, then repair in a similar fashion to inguinal hernia.
What is a femoral hernia?
Usually traumatic. herniation of organs through femoral canal. femoral artery vein and nerve located there, repair difficult. Be aware they exist. be aware they are usually misdiagnosed as inguinal hernias. refer for repair.
What is a perineal hernia?
Pelvic diaphragm degenerates. Rectum, prostate and abdominal organs herniate. Acquired degeneration of pelvic diaphragm, levator ani muscle. May be linked to androgens, straining (prostate), neurogenic muscle atrophy. Seen in mature, male entire dogs (93%), occasionally male neutered and female. can be unilateral or bilateral . right > left. The rectum: deviates + dilates. may be abdominal fat, prostate or retroflexed bladder. Presentation - faecal tenesmus, perineal swelling, constipation. If retroflexed bladder - dysuria, systemic collapse/acute renal failure. For bladder - cystocentesis or urinary catheterisation, reduce hernia - with digital pressure. leave indwelling urethral catheter until surgery. Treatment - with simple herniorrhaphy, or internal obturator muscle transposition flap. Castration reduces risk of recurrence. Complications: recurrence, rectal eversion/prolapse, suture penetrating rectal mucosa, faecal incontinence, sciatic nerve injury.
What are the indications for colonic surgery?
Biopsy, neoplasia, obstipation, fb removal rare. Must consider - gram negative anaerobes, highest bacterial flora, perioperative antibiotics indicated. Colon has linear blood supply, poor collateral circulation, care not to cause ischaemia.
What is megacolon?
Large intestinal enlargement and hypomotility with sever constipation/obstipation. Congenital megacolon (rare) - primary or secondary (imperforate anus).
Acquired megacolon idiopathic common in cats, secondary to colonic obstruction, (functional obstruction, intraluminal, mural, extraluminal obstruction) secondary to colonic inertia. Intraluminal and mural obstruction may be foreign body, neoplasia, stricture. Extraluminal - caused by pelvic fracture >50% narrowing, intrapelvic mass, prostatic disease, perineal neoplasia, pain. Functional colonic obstructions include acquired dysautonomias, neurological injury.
Describe feline idiopathic megacolon?
It is the most common form of megacolon. an acquired disorder. Uncertain aetiology - environment, stress, obesity, primary colonic inertia. Regardless of aetiology retained faeces becomes dry and impacted. large faecoliths physically difficult to pass. chronic stretching injury to colonic wall. self perpetuating cycle. prognosis for return to normal colonic function is poor. Investigation - repeated episode of constipation, neurological exam, rectal exam, radiographs eg fractured pelvis.
How is megacolon managed?
Rehydrate and support patient. Evacuate colon with enemas or digital evacuation. dietary modification, laxatives, prokinetic agents - aim for defecation at least once every 48 hours.
What is a colotomy?
it is of no long term benefit for megacolon. colonic function is unlikely to return. invasive short term measure that should not be recommended.
What is subtotal colectomy?
Used for feline megacolon. very sucessful. remove 90-95% of colon. removal of ileocaecocolic junction. Dogs do not tolerate this surgery. refer for surgery. Postop diarrhoea is inevitable. managable within 2 weeks. clip perineum and warn owners. faecal incontinence may occur - rare in long term. recurrence of megacolon in residual section of colon.
Describe large intestinal neoplasia
Common in dogs. rectum > colon. adenomatous polyps, adenocarcinoma. Colorectal adenocarcinoma - rectum most common place. they form strictures. may be annular (intramural) or intraluminal) they are extremely aggressive - poor prognosis. medical - piroxicam. surgical- 3cm margins, rectal pull through.
What are colorectal polyps?
usually at anocutaneous junction. pedunculated. do not invade into submucosa. local resection generally curative.
Describe anal sac disease
Anal sacculitis (impaction and infection) Anal sac abscess + rupture Apocrine gland adenocarcinoma - 90% female, 50% metastasised by the time of diagnosis, cause pseudohyperparathyroidism, poor prognosis. Treat with anal sacculectomy.
What causes rectal prolapse & how should it be treated?
Secondary to causes of tenesmus, should be treated as an emergency. manual reduction or surgical management.
What are the functions & components of diarthrodial joints
They allow movement, provide stabilisation. They are made up of articular cartilage, synovial membrane/fluid, joint capsule and ligaments, other structures - intra articular fat pads, menisci.
Articular cartilage has 4 distinct layers - chondrocytes, extracellular matrix - type II collagen, proteoglycan matrix.
What are the functions of articular cartilage?
Low friction, protect bone, growth zone.
Synovial membrane;
Intimal layer - type A synoviocytes (macrophages) and type B synoviocytes( fibroblasts).
Sub intimal layer - blood vessels, lymphatics, connective tissue.
Why are perioperative antibiotics used in liver surgery?
There is an anaerobic (clostridial) residual population - which may proliferate in ischaemic liver tissue.
Describe the blood supply to the liver
Portal vein - stomach, intestines, spleen, pancreas - 80%
Hepatic artery - 20%
Why may a liver biopsy be done?
Diagnosis of diffuse hepatopathy, diagnosis of heritable disease e.g copper toxicosis of bedlington terriers, diagnosis of isolated liver lesions. Can either do an ultrasound guided needle biopsy or a surgical biopsy - safer for patients with coagulopathies to do surgical biopsy as bleeding can be visualised and addressed by methods that do not rely on coagulation cascade. Use guillotine method or for focal liver biopsy - gullotine technique.
What is a portosystemic shunt?
Common congenital liver disease, easily missed during evaluation of signs. requires specialist assessment for medical and surgical therapy. Anomalous vessels enable portal blood to bypass the liver. portal blood passes directly into the systemic circulation. Systemic effects of PSS - stunting, failure to thrive, hypoalbuminaemia, hepatic encephalopathy, dullness, aggression, failure to house train, seizures, PUPD, urate crystalluria. Extrahepatic more common in small breed, intrahepatic vessel shunts more common in large breed dogs. Cats get either. Biochemical changes: liver dysfunction, high postprandial bile acids. Diagnosis with ultrasound, portal venography, nuclear scintigraphy,
What is microhepatica?
Loose up to 80% of blood supply to liver. lose hepatotrophic factors in portal blood, chronic liver insufficiency. Seen with pss.
What is the management of portosystemic shunt?
Medical management - manage hepatic encephalopathy, manage liver dysfunction, give small frequent meals regularly. quality of life and life expectancy may be reduced.
Surgical management - increase hepatic blood flow by closing anomalous vessel - overall quality of life improved, life expectancy may be higher, 5-10% mortality rate, unpredictable responses to surgery.
What are the indications for surgery in the extrahepatic biliary tree?
Biliary obstruction - pancreatitis, cholelith.
Biliary trauma
Proximal duodenal resections
Cholecystectomy
Choledochotomy
Cholecystojejunostomy
High morbidity and mortality. results influenced by experience - refer.
