SURGERY - Gastrointestinal Surgery Flashcards
What is a laparotomy?
A laparotomy is an incision into the abdomen
What is another term used to describe a laparotomy?
Coeliotomy
Where should you incise when carrying out a ventral midline laparotomy?
When carrying out a ventral midline laparotomy, you should make an adequate incision for what surgery you are going to perform. For example, if you are doing an ovariohysterectomy, you should incise the caudal abdomen, but if you are doing an exploratory laparotomy, you should do a full abdominal incision
Where should you clip to prepare the patient for a laparotomy?
You should clip the hair from the midsternum to past the pubis and to the flank fold laterally to allow you so extend the incision if necessary
Which method of draping should you use for a laparotomy?
You should use four quarter draping method for a laparotomy
What is the purpose of abdominal retractors?
Abdominal retractors are used to maximise exposure of the abdomen
Identify this type of abdominal retractor
Gosset retractor
Identify this type of abdominal retractor
Balfour retractor
What can you use to prevent tissue dessication during a laparotomy?
Swabs moistened with saline can be used to prevent tissue dessication during a laparotomy
How much blood do 10x10cm swabs hold?
10x10cm swabs hold approximately 10mls of blood each
How much blood do 30x30cm swabs hold?
30x30cm swabs hold approximately 100mls of blood each
What should you also do when using swabs during a surgical procedure?
When using swabs during a surgical procedure, you should always count your swabs at the start and end of the procedure
Which layers of tissue are you incising during a laparotomy?
Skin
Subcutaneous tissue
Linea alba
Peritoneum
Potentially falciform fat
What are the steps involved in a laparotomy?
- Incise the skin using a scalpel
- Incise the subcutaneous tissue using mayo scissors for blunt dissection
- Grasp the linea alba with rat tooth forceps and tent it up. Carry out a stab incision using the scalpel (remember to keep scalpel blade facing away from the abdominal contents) and carefully extend the incision using mayo scissors
- Excise the falciform fat if incising into the cranial abdomen to improve exposure
How do you excise the falciform fat?
To excise the falciform fat, clamp and place a cerclage ligature at the the base of the falciform fat at the level of the xiphisternum followed by cutting the fat and removing it
Which additional steps should be taken when performing a laparotomy on a male dog?
When performing a laparotomy on a male dog, the prepuce must be clipped to the side and draped. If incising the caudal abdomen, you will need to extend the incision around the penis. When you do this, you will encounter the branch of the caudal superficial epigastric artery and vein which will need to be ligated as well as cut through the cranial prepucial muscle before incising along the linea
What is an exploratory laparotomy?
An exploratory laparotomy is a systematic exploration of the entire abdomen
Which systematic approach should you use when carrying out an exploratory laparotomy?
Four quadrant approach
Which quadrants are assessed during the four quadrant approach for an exploratory laparotomy?
Cranial quadrant
Right quadrant
Left quadrant
Caudal quadrant
Central compartment
Which structures should you assess in the cranial quadrant when carrying out an exploratory laparotomy?
Diaphragm
Liver
Gallbladder
Stomach
Spleen
Left limb of the pancreas
What should you do to provide better exposure of the right quadrant?
Use the mesoduodenum to form a sling which will pull back the intestines to provide better exposure of the right quadrant
Which structures should you assess in the right quadrant when carrying out an exploratory laparotomy?
Right kidney
Right ureter
Right adrenal gland
Right ovary
Right limb of the pancreas
Caudal vena cava
What should you do to provide better exposure of the left quadrant?
Use the mesocolon to form a sling which will pull back the intestines to provide better exposure of the left quadrant
Which structures should you assess in the left quadrant when carrying out an exploratory laparotomy?
Left kidney
Left ureter
Left adrenal gland
Left ovary
Which structures should you assess in the caudal quadrant when carrying out an exploratory laparotomy?
Colon
Bladder
Proximal urethra
Prostate
Inguinal canals
Which structures should you assess in the central compartment when carrying out an exploratory laparotomy?
Start from the pylorus and work your way along the entire small and large intestine. Make sure to also assess the mesentery and the omentum
What are the steps involved in abdominal closure?
- Put all of the organs back into the abdomen
- Ensure all swabs have been removed from the abdomen
- When closing the linea alba, make sure to include the external rectus sheath in each suture bite as this is what provides strength to the closure
- Suture the subcutaneous tissue
- Suture the skin
Which suture patterns can you use to close the linea alba?
Simple interrupted
Simple continuous
How many throws should you do per knot if you are using a simple continuous suture pattern to close the linea alba?
If you are using a simple continuous suture pattern to close the abdomen, you should use 5 throws for the knot at the start and 7 throws for the knot at the end
Which suture material should you use to close the linea alba?
Long lasting monofilament synthetic absorbable suture material of an appropriate size
Give an example of an appropriate suture material for closing the linea alba
Polydioxanone (PDS)
What can you do to limit the risk of contamination when carrying out gastrointestinal surgery?
- Exteriorise the portion of gastrointestinal tract being operated on
- Isolate the area being operated on with moistened swabs
- Have a ‘dirty contaminated’ area on your trolley to prevent contamination of sterilised instruments
- Handle any foreign bodies with instuments and then discard these
- Change your gloves and surgical instruments one the gastrointestinal tract has been closed before continuing with closure
- Lavage the abdomen with 100-200ml/kg warm saline/hartmann’s at the end of surgery
Which additional surgical instruments do you require for gastrointestinal surgery?
Bowel clamps (Doyens)
Atraumatic forceps
What is the purpose of bowel clamps (Doyens)?
Bowel clamps (Doyens) are used to occlude the lumen of the intestines as they are specially designed to handle delicate stuctures
However people can also use their fingers to achieve this
What type of needles should you use for suturing gastrointestinal surgery?
Round body, taper point swaged on needles
What are the steps involved in a gastrotomy?
- Cranial abdominal midline incision is made from the xiphoid to the umbilicus
- The stomach is mobilised and stay sutures should be placed on the stomach wall to elevate it out of the lapatomy incision
- Place moistened swabs around the stomach tp protect the rest of the abdomen in case of spillage of gastric contents
- A gastrotomy incision is made into the stomach between the greater and lesser curvatures where it is less vascular
- The gastrotomy incision can be extended with Metzenbaum scissors to the appropriate size for foreign body removal
- Use simple continuous for closing the mucosa and submucosa (make sure to include the submucosa in your closure)
- Use cushings of lembert to close the seromuscular layer
How do you determine intestinal viability?
- Viable intestine will have peristalsis however non-viable intestine will not (however be aware the handling the intestine can cause ileus which complicates things)
- Viable intestine is pink in colour. Compromised intestine will be red/erythematous. Non-viable bowel can be black/blue/purple/green
- Viable intestine will bleed perfusely
- Thinning of the intestine can indicate necrosis
- If the intestine is viable, the mesenteric blood supply should have a pulse
What are the steps involved in a enterotomy?
- Abdominal ventral midline incision is made
- Identify the area of intestine requiring an enterotomy and check the intestine is viable if not, then an enterectomy would be more appropriate
- Exteriorise the area of small intestine by gentle retraction
- Place moistened swabs around and deep to the affected small intestine to protect the rest of the abdomen in case of spillage of intestinal contents
- Milk the intestinal contents away from the affected site
- Place bowel (Doyen) clamps or use your assistants fingers to occlude proximal and distal to the affected site
- Make a longitutinal incision in the antimesenteric border of the small intestine using a scalpel. In the presence of a foreign body, aim to make the incision in a normal, non-dilated portion of intestine
- Remove the foreign body with surgical instruments
- Close the intestine (making sure to include the submucosa) using an appositional suture pattern (either simple interrupted or simple continuous), taking 3 - 4 mm bites
- Perform a leak test
- Place an omental wrap and secure it with sutures
How do you perform a leak test after performing an enterotomy?
To carry out a leak test, occlude the intestine and using a 25g needle, inject 5mins of saline into the intestine followed by applying gently pressure and observing for any leakage
What is an omental wrap?
An omental wrap is where for gastrointestinal surgery, you wrap the omentum around the suture line and secure it in place with more sutures
When is an enterectomy the most appropriate form of small intestinal surgery?
An enterectomy is most appropriate when the small intestine is non-viable, or for removal of intestinal neoplasia and intussusception
What are the steps involved in a enterectomy?
- Carry out a ventral midline laparotomy
- Identify and exteriorise the area of small intestine that is going to be resected, allowing for a margin of healthy tissue
- Place moistened swabs around and deep to the affected area to protect the rest of the abdomen in case of spillage of intestinal contents
- Milk the intestinal contents away from the site to be resected
- Place crushing clamps to occlude proximal and distal to the site that is to be resected and place bowel (Doyen) clamps on the portion of small intestine you want to suture
- Double ligate the blood vessels which supply the length of the small intestine to be resected and incise the mesentery between the vessels
- Excise the portion of intestine along the crushing clamps, bowel (Doyen) clamps, placed a small distance away from the resection site, will minimise spillage
- Close the intestine (making sure to include the submucosa) using simple interrupted appositional sutures
- Place your first suture at the mesenteric border of the intestine, your second suture at your antimesenteric border of the intestine and then fill in the gaps between te two with sutures 3mm apart
- Perform a leak test
- Close the mesentery using a simple continuous suture
- Place an omental wrap and secure it with sutures
Where is there most likely to be a leak following an enterectomy?
Following an enterectomy, there is most likely to be a leak on the mesenteric border on the intestine as the presence of the mesenteric fat makes the sutures challenging to place, making it the most common site for leakage
What are the two methods you can use to manage a luminal disparity during an enterectomy?
- Cut the smaller portion of the intestine at an angle to create a larger diameter
- Carry out a lineal incision along the antimesenteric border of the small portion of the small intestine to create a greater cut edge to suture
What is intussusception?
Intussusception is the invagaination of a portion of the intestine into the lumen of another
What are the key signs of intussusception on ultrasound?
Intussusception has an ‘onion-like’ appearance on ultrasound due to the multiple layers of intestinal wall due to the telescoping of the intestine. Furthermore, there will be regions of mesenteric fat that have been pulled into the intestine
What is enteroplication?
Enteroplication is a surgical technique where you suture adjacent loops of the small intestine together on the antimesenteric surfaces to prevent recurrence of intussusception
What is a linear foreign body?
A linear foreign body describes long thin objects (such as string etc) which can become anchored under the tongue and swallowed into the gastrointestinal tract where the intestines can become bunched up around the linear foreign body
What are the key signs of a linear foreign body on radiography?
Intestines appear bunched up with an undulating outline and comma shaped gas bubbles
What are the key signs of a linear foreign body on ultrasound?
Intestinal plication
Foreign body material usually appears centrally
How do you treat a linear foreign body?
Removal of a linear foreign body requires a gastrotomy and multiple enterotomies to remove the linear foreign body in sections. Severe intestinal damage may require an enterectomy and maybe even euthanasia
