Soft Tissue Surgery: GI surgery Flashcards
What is the duodenal dam manoeuvre?
Grasp the duodenum and retract most of the intestines over to the left to expose the right abdominal roof
What is the colonic dam manoeuvre?
Grasp the colon and retract most of the intestines to the left to examine the left abdominal roof
- How can intestines be kept moist during surgery?
- When are stay sutures indicated?
- Saline usine a bulb syringe or cover with moistened abdominal swabs
- Handling tissues- stomach and gall bladder- 3-4 stay sutures
What extra instruments can be good for abdominal surgery?
- Self-retaining abdominal retractors
- Malleable retractors
- Suction- essential for lavage
- Debakey thumb forceps- least traumatic
- Doyen bowel forceps or allis tissue forceps
- Crushing forceps to occlude the lumen of gut
The least vascular parts of the gut wall should be incised
Where is best?
- Midway between the greater and lesser curvature of the stomach
- Antimesenteric border of the duodenum, jejunum or colon
- Approx 2/3 of the way from mesenteric to antimesenteric border of the ileum
How should the GI tract be ligated?
Capillary ooze- small vessels, stops when sutured
Larger vessels- ligate, avoid cautery on gas filled
Oesophagus- ligate and divide segmental BVs as required
SI
* Ligate branches of cranial mesenteric and the terminal arcade vessels running along the mesenteic border
Colon depends on what tissue is being resected
How is the liver operated on preventing haemorrhage?
- Check coagulopathies
- Topical haemostatic agents
- Pringle manoeuvre- occlude blood flor for 15m
- Resections- tempory occlusion with combination of ligatures and tourniquets
- Guillotine method- near the border
How is a partial lobectomy away from the border or total done?
Finger fracture technique
* Incise liver capsule
* crush/seperate the parenchyma along that line with fingers to expose the large vessels and bile ducts to ligate
How is pancreas haemostasis performed?
- Pass ligature around the area containing lesion of haemorrhaging
- Bluntly seperate pancreatic lobules around the lesion, isolate blood vessels and ducts ligate
when sectioning intestine what how should it be incised?
30 degrees to the transverse- ensures adequate blood supply
when sectioning intestine what how should it be incised?
30 degrees to the transverse- ensures adequate blood supply
How can intestine viability be subjectively and objectively?
Subjective
* Colour- healthy pink
* Arterial pulsations
* Peristalsis
Objective
* Pulse oximetry
* Inject fluroescein dye IV
Why can thoracic oesophagus tolerate ligation of segmental blood vessels?
- Has a rich submucosal plexus of blood vessels
- Avoid cautery
Similar for the jejunum
- What can resection of the duodenum compramise blood supply to?
- What needs to be preserved on a splenecomty for the stomach?
- What needs to be avoided around the pylorus?
- Pancreatic blood supply
- Left gastroepiploic artery
- Cranial pancreaticoduodenal and hepatic arteries
How can contamination of the peritoneal cavity be minimalised during surgery?
- Use moistened swabs
- Before opening intestine- milk contents from incision site
- Elevate the oesophagus and stomach with stay sutures
- Discard contaminated instruments and gloves
- After lavage with 1-3L of warm water
When should prophylactic ABs be used for GIT surgery?
IV just after induction
* Clavulanate-amoxicillin- common contaminants
* Colonic or hepatic surgery- metronidazole (anaerobes)
* Amoxicillin- bile
Where are issues of tension in the GI?
Oesophagus and proximal colon
What is required for accurate tissue apposition of the GI?
Submucosa
* High collagen content
* Must be incorporate into suture line
What are the two closure techniques of the GI for longitudinal incisions
- Longitudinal closure- general purpose
- Transverse- maintains lumen diameter, small patients
Transverse incisions may cause stricture
How is section of intestine sutured together?
End to end appositional anastomosis
What suture material is used for most intestinal surgery?
2 metric or 1.5 monofilament, synthetic absorbable
Can use nonabsorbable for colonic surgery
What suture patterns are used in GI sugery?
- Simple interupted or continuous
- Oesophagus- single later blosure
- Stomach- 2 layer closure- simple then inverting cushing
- 3-4mm from cut edge and 3mm apart
- Check by injecting sterile saline
How can luminal disparity be dealt with?
Different diameters
* Eliminate gaps by spacing sutures further apart on the larger side
How is the mesentery closed?
Simple continous synthetic monofilament
How can the omentum be used to an advantage of GI surgery?
Omental wrapping:
* protects GI incisions
* Increases local tissue O2
* Promotes angiogenesis
* Phagocytic immunity
* Seal
* Or serosal patching- suture intestine to itself
What fluid and electrolyte imbalance is acceptable before GI surgery?
Correct to 50-75% before
What are complications of GIT surgery?
- Peritonitis
- Adhesions
- Small bowel syndrome
- Strictures
- What causes primary and secondary peritonitis?
- What are the clinical signs?
- What is the pathophysiology?
- Primary- rare- FIP, secondary chemical (bile), septic (necrosis/perforation)
- Variable- depression, anorexia, abdominal pain, ileus, pyrexia, shock
- Hypovolaemia- decreased fluid intake, losses from vomiting/diarrhoea, metabolic acidosis form decreased tissue perfusion, electrolyte imbalance, endotoxic shock
How is peritonititis diagnosed?
- Radiography- loss of abdominal detail
- Haem- left shift
- Biochem- azotaemia
- Abdominal paracentesis- US
- C&S
How is peritonitis treated?
- Correct fluid and acid/base imbalance
- Broad spec ABs
- Correct cause
- Lavage
- Drainage
What causes adhesions?
Tissue anoxia, serosal injury, FB
Can be restrictive
Minimise with appropriate tissue handling, removing blood clots
What is short bowel syndrome?
How is it medically managed?
Removal of about 80% SI
* Maldigestion- reduced pancreas secretions
* Malabsorption- reduced SA
* Bile salt deficiency- enterohepatic circulation
Medical managment
* Frequent small low fat meals
* Diet supplements
* Medium chain triglyceride oil
* Oral antidiarrhoeals, ABs, antacids
Poor prognosis
What is ileus?
What are the clinical signs?
What is the treatment?
- Inadequate peristaltic activity of the entire GI, functional obstruction
- Vomiting, diarrhoea, fluid and gas retention
- Difficult- address cause, correct fluid and electrolyte imbalance, normalise motility
How can the oesophagus be approached?
- Access to level of second rib via a cervical midline
- Access the intrathoracic via intercostal thoracotomy
How is the terminal colon, rectum and anus approached?
Ventral approach
* split pelvis- colorectal junction
Anal approach
* Suitable for foal lesions close to anus- every anus
Pull through approach- distal colonic or mid-rectal lesions
* evert rectal wall through anus and transect distal rectum
Dorsal- caudal or middle rectum
* Inverted U incision dorsal to anus
Lateral- between external anal sphincter and levator ani
