SURGERY - Gastrointestinal Surgery Flashcards
1
Q
What is a laparotomy?
A
A laparotomy is an incision into the abdomen
2
Q
What is another term used to describe a laparotomy?
A
Coeliotomy
3
Q
Where should you incise when carrying out a ventral midline laparotomy?
A
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
4
Q
Where should you clip to prepare the patient for a laparotomy?
A
You should clip the hair from the midsternum to past the pubis and to the flank folds laterally to allow you so extend the incision if necessary
5
Q
Which method of draping should you use for a laparotomy?
A
You should use four quarter draping method for a laparotomy
6
Q
What is the purpose of abdominal retractors?
A
Abdominal retractors are used to maximise exposure of the abdomen
7
Q
Identify this type of abdominal retractor
A
Gosset retractor
8
Q
Identify this type of abdominal retractor
A
Balfour retractor
9
Q
What can you use to prevent tissue dessication during a laparotomy?
A
Swabs moistened with saline can be used to prevent tissue dessication during a laparotomy
10
Q
How much blood do 10x10cm swabs hold?
A
10x10cm swabs hold approximately 10mls of blood each
11
Q
How much blood do 30x30cm swabs hold?
A
30x30cm swabs hold approximately 100mls of blood each
12
Q
What should you also do when using swabs during a surgical procedure?
A
When using swabs during a surgical procedure, you should always count your swabs at the start and end of the procedure
13
Q
Which layers of tissue are you incising during a ventral midline laparotomy?
A
Skin
Subcutaneous tissue
Linea alba
Peritoneum
Potentially falciform fat
14
Q
What are the steps involved in a ventral midline laparotomy?
A
- 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
15
Q
How do you excise the falciform fat?
A
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
16
Q
Which additional steps should be taken when performing a laparotomy on a male dog?
A
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
17
Q
What is an exploratory laparotomy?
A
An exploratory laparotomy is a systematic exploration of the entire abdomen
18
Q
Which systematic approach should you use when carrying out an exploratory laparotomy?
A
Four quadrant approach
19
Q
Which quadrants are assessed during the four quadrant approach for an exploratory laparotomy?
A
Cranial quadrant
Right quadrant
Left quadrant
Caudal quadrant
Central compartment
20
Q
Which structures should you assess in the cranial quadrant when carrying out an exploratory laparotomy?
A
Diaphragm
Liver
Gallbladder
Stomach
Spleen
Left limb of the pancreas
21
Q
What should you do to provide better exposure of the right quadrant?
A
Use the mesoduodenum to form a sling which will pull back the intestines to provide better exposure of the right quadrant
22
Q
Which structures should you assess in the right quadrant when carrying out an exploratory laparotomy?
A
Right kidney
Right ureter
Right adrenal gland
Right ovary
Right limb of the pancreas
Caudal vena cava
23
Q
What should you do to provide better exposure of the left quadrant?
A
Use the mesocolon to form a sling which will pull back the intestines to provide better exposure of the left quadrant
24
Q
Which structures should you assess in the left quadrant when carrying out an exploratory laparotomy?
A
Left kidney
Left ureter
Left adrenal gland
Left ovary
25
Which structures should you assess in the caudal quadrant when carrying out an exploratory laparotomy?
Colon
Bladder
Proximal urethra
Prostate
Inguinal canals
26
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
27
What are the steps involved in abdominal closure?
1. Put all of the organs back into the abdomen
2. Ensure all swabs have been removed from the abdomen
3. 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
4. Suture the subcutaneous tissue
5. Suture the skin
28
Which suture patterns can you use to close the linea alba?
Simple interrupted
Simple continuous
29
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
30
Which suture material should you use to close the linea alba?
Long lasting monofilament synthetic absorbable suture material of an appropriate size
31
Give an example of an appropriate suture material for closing the linea alba
Polydioxanone (PDS)
32
What can you do to limit the risk of contamination when carrying out gastrointestinal surgery?
1. Exteriorise the portion of gastrointestinal tract being operated on
2. Isolate the area being operated on with moistened swabs
3. Have a 'dirty contaminated' area on your trolley to prevent contamination of sterilised instruments
4. Handle any foreign bodies with instuments and then discard these
5. Change your gloves and surgical instruments one the gastrointestinal tract has been closed before continuing with closure
6. Lavage the abdomen with **100-200ml/kg** warm saline/hartmann's at the end of surgery
33
Which additional surgical instruments do you require for gastrointestinal surgery?
Bowel clamps (Doyens)
Atraumatic forceps
34
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
35
What type of needles should you use for suturing gastrointestinal surgery?
Round body, taper point swaged on needles
36
Which suture material should you use for gastrointestinal surgery?
Monofilament synthetic absorbable suture material
37
Give three examples of suture material appropriate for gastrointestinal surgery
Polydioxanone (PDS)
Poliglecaprone 25 (monocryl)
Glycomer 631
38
Which suture patterns are appropriate for gastric surgery?
Simple continuous for the mucosa and submucosa
Cushings or Lambert for the seromuscular layer
39
Which suture patterns are appropriate for small intestinal surgery?
Simple interrupted
Simple continuous
40
Why is it important to use an appositional suture pattern to close the small intestine?
It is important to use an appositional suture pattern to close the small intestine as an inverted suture pattern will narrow the intestinal lumen
41
Why is it so important that your sutures incorparate the submucosa when closing gastrointestinal incisions?
The submuscosa is the strongest layer in the gastric and small intestinal wall so it is essential that it is incorporated
42
What is a gastrotomy?
A gastrotomy is a surgical incision into the stomach
43
What is the most common indication for a gastrotomy?
Gastric foreign bodies that cannot be removed via emesis or endoscopically
44
What are the steps involved in a gastrotomy?
1. Cranial abdominal midline incision is made from the xiphoid to the umbilicus
2. The stomach is mobilised and stay sutures should be placed on the stomach wall to elevate it out of the lapatomy incision
3. Place moistened swabs around the stomach to protect the rest of the abdomen in case of spillage of gastric contents
4. A gastrotomy incision is made into the stomach between the greater and lesser curvatures where it is less vascular
5. The gastrotomy incision can be extended with Metzenbaum scissors to the appropriate size for foreign body removal
6. Use simple continuous for closing the mucosa and submucosa *(make sure to include the submucosa in your closure)*
6. Use cushings of lembert to close the seromuscular layer
45
What are stay sutures?
Stay sutures are temporary surgical sutures that are placed during surgery to hold or manipulate the operating area
46
What are the indications for small intestinal surgery?
Foreign body
Neoplasia
Intussusception
Intestinal volvulus/strangulation
Linear foreign body
47
Why is it so important to determine if intestine is viable or non-viable?
It is important to determine if intestine is viable or non-viable as non-viable tissue must be removed or it will become ischeamic, necrotic and perforate
48
How do you determine intestinal viability?
1. Viable intestine will have peristalsis however non-viable intestine will not *(however be aware the handling the intestine can cause ileus which complicates things)*
2. Viable intestine is pink in colour. Compromised intestine will be red/erythematous. Non-viable bowel can be black/blue/purple/green
3. Viable intestine will bleed perfusely
4. Thinning of the intestine can indicate necrosis
5. If the intestine is viable, the mesenteric blood supply should have a pulse
49
What is an enterotomy?
An enterotomy is a surgical incision into the small intestine
50
When is an enterotomy the most appropriate form of small intestinal surgery?
An enterotomy is only appropriate for foreign body removal from **viable** small intestine
51
What are the steps involved in a enterotomy?
1. Abdominal ventral midline incision is made
2. Identify the area of intestine requiring an enterotomy and check the intestine is viable **if not, then an enterectomy would be more appropriate**
3. Exteriorise the area of small intestine by gentle retraction
4. 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
5. Milk the intestinal contents away from the affected site
6. Place bowel (Doyen) clamps or use your assistants fingers to occlude proximal and distal to the affected site
7. 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
8. Remove the foreign body with surgical instruments
9. 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
10. Perform a leak test
11. Place an omental wrap and secure it with sutures
52
Why is it important to make the intestinal incision in normal, non-dilated tissue when performing an enterotomy?
It is important to make the intestinal incision in normal, non-dilated tissue when performing an enterotomy as this allows for the sutures to be placed in healthier intestine to decrease the risk of dehiscence
53
What is dehiscence?
Dehiscence is where the surgical incision breaks down and re-opens
54
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 5ml of saline into the intestine followed by applying gently pressure and observing for any leakage
55
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
56
What are the benefits of an omental wrap?
Promotes serosal sealing
Speeds up healing
Increases the blood supply
Stimulates angiogenesis
Reduces leakage
57
What is an enterectomy?
An enterectomy is the surgical removal of a portion of the small intestine
58
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
59
What are the steps involved in a enterectomy?
1. Carry out a ventral midline laparotomy
2. Identify and exteriorise the area of small intestine that is going to be resected, allowing for a margin of healthy tissue
3. Place moistened swabs around and deep to the affected area to protect the rest of the abdomen in case of spillage of intestinal contents
5. Milk the intestinal contents away from the site to be resected
6. 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
7. Double ligate the blood vessels which supply the length of the small intestine to be resected and incise the mesentery between the vessels
8. Excise the portion of intestine along the crushing clamps, bowel (Doyen) clamps, placed a small distance away from the resection site, will minimise spillage
9. Close the intestine (making sure to include the submucosa) using simple interrupted appositional sutures
10. Place your first suture at the mesenteric border of the intestine, your second suture at your antimesenteric border of the intestine, then at 3 o'clock, then at 9 o'clock, and then fill in the gaps between te two with sutures 3mm apart
11. Perform a leak test
12. Close the mesentery using a simple continuous suture (if you don't suture the mesentery, loops of intestine will get trapped in the hole)
13. Place an omental wrap and secure it with sutures
## Footnote
https://www.youtube.com/watch?v=ZzEdo43ZSxM
60
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
61
What is luminal disparity?
Luminal disparity is where the proximal and distal segments of the small intestine that you need to suture together are not the same size
62
What are the two methods you can use to manage a luminal disparity during an enterectomy?
1. Cut the smaller portion of the intestine at an angle to create a larger diameter
2. Carry out a linear incision along the antimesenteric border of the small portion of the small intestine to create a greater cut edge to suture
63
What are the steps of an abdominal closure after all gastrointestinal surgery?
1. After the gastrointestinal tract is closed, change your gloves and surgical instruments
2. Lavage the abdomen with 100-200ml/kg of WARM saline/hartmanns
3. Count your swabs and surgical instruments
4. Carry out a routine abdominal closure
64
What is intussusception?
Intussusception is the invagaination of a portion of the intestine into the lumen of another
65
What is intussusception associated with?
Intussusception is associated with any gastrointestinal disease which causes hypermotility
66
What are the common causes of intussusception in young animals?
Enteritis *(causing diarrhoea)*
Heavy worm burden
Spontaneous
67
What is the most common cause of intussusception in older animals?
Neoplasia
68
How does intussusception feel on abdominal palpation?
The intestines will feel 'sausage-like' on abdominal palpation
69
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
70
How can you treat intussusception?
Reduction (pull the telescoping intestine out)
Enterectomy if the intestine is non-viable
| https://www.youtube.com/watch?v=vuB_2y51K8Y&t=4s
71
Which factors should you be aware of when using reduction to treat intussusception?
Can only be done in young animals
Risk of recurrence
72
When is an enterectomy the most appropriate method for treating intussusception?
Treating older animals with intussusception
Younger patients if it is non-reducible or the tissues are non-viable
Chronic intussusceptions which may be adhesed and non-reducible
73
What should you do after performing an enterectomy to treat intusussception in an older animal?
You should send the resected tissue for histology for further investigation as the intussusception is likely secondary to neoplasia
74
Which technique can be considered to treat recurring intussusception?
Enteroplication
75
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
76
Why is enteroplication so controversial?
Enteroplication is so controversial as it can have life-threatening complications
77
Describe the pathology of a linear foreign body
A linear foreign body describes long thin objects *(such as string etc)* which can become anchored under the tongue or at the pylorus move down the intestine under periastalsis and due to being anchored further up the tract the linear foreigh body will become taught causing the intestines to become bunched up around the linear foreign body, and the linear foreign body can dig into the the mesenteric border of the intestine. This can result in perforation and peritonitis (which usually requires euthanasia at this point)
78
What are the key signs of a linear foreign body on radiography?
Intestines appear bunched up with an plicated outline and comma shaped gas bubbles
79
What are the key signs of a linear foreign body on ultrasound?
Intestinal plication
Foreign body material usually appears centrally
80
How do you treat a linear foreign body?
1. Cut the linear foreign body to free it from the tongue or perform a gastrotomy and release the start of the foreign body which is usually caught at the pylorus
2. Estimate where the middle of the foreign body is along the intestinal tract and make a small enterotomy incision here
3. Use haemostats to lift the foreign body out of the intestine and cut it
4. Apply mild traction to one end and judge where to make the next enterotomy
5. Work down the intestine making the enterotomies are spaced out to cut and retrieve the foreign body in short segments
6. Repeat working along the other half of the foreign body until it is all removed
7. Enterectomy may be required if tissue is non-viable. Euthanasia may be indicated if the intestine has perforated or there is peritonitis
81
When is it recommended to begin refeeding patients following gastrointestinal surgery?
Recommended to feed after surgery as soon as they are conscious enough to eat as feeding is essential for mucosal health and nutrition is needed for optimal healing
