The Stomach and General Principles of Gastric Surgery Flashcards
Which organ is in close association with the cranial/ventral aspect of the stomach?
Liver
Which part of the stomach lies against the diaphragm?
Fundus
Which structures form the lateral part of the abdominal wall on the right and left side of the normal stomach?
Costal arch
What structure attaches to the greater curvature of the stomach?
Greater omentum
Which structure lies immediately caudal to the stomach?
contact with the transverse colon which crosses the abdomen from right to left immediately caudal to the stomach
What side of the abdomen is the pylorus located on?
Right
What is the cone shaped portion of the stomach that funnels gastric contents towards the pylorus?
Pyloric antrum
How to perform the gastric axis?
If you draw a line from the “top” to the “bottom” of the stomach on a lateral abdominal radiograph this gives you the gastric axis.
What does the gastric axis show us?
If the liver is normal in size the gastric axis should be roughly parallel to the ribs on a lateral abdominal radiograph.
What structure is cranial to and merges with the cardia?
Oesophagus
What structure runs in the hepatoduodenal ligament?
Common bile duct
Which way does the transverse colon cross the abdo?
Right to left
Why is the stomach not palpable on CE?
Lies within costal arch
What lies immediately caudal to the body of the stomach on the left side of the abdomen?
Head of the spleen
What is the spleen attached to the stomach by?
Gastrosplenic ligament
What are the 5 areas of the stomach?
Cardia
Fundus
Body
Pyloric antrum
Pylorus
Where is the cardia located cf to midline?
It is fixed/non-movable + located immediately where cf t diaphragm?
- Left
- Caudal
Which side is the fundus?
Left
The cranial surface of the fundus pushes
Against the left upper part of the diaphragm.
What is the largest part of the stomach?
Body
Body of the stomach:
A) Where does it join the fundus?
B) Where does it join the pyloric antrum?
A) Left
B) Right
What does the pyloric antrum connect?
Body to pylorus
Where is the pylorus located?
R ventral abdo
How many muscle layers is the pylorus?
Double
Shape of greater curvature?
Convex
Shaper of lesser curvature?
Concave
What are the 2 leaves of omentum?
Ventral and dorsal
Where does the left limb of pancreas lie in the omentum?
Dorsal
Which ligament is formed by a portion of the lesser omentum?
Hepatogastric
The hepatogastric ligament merges with what and where?
Hepatoduodenal lig. on right
The hepatogastric ligament anchors what?
Stomach to liver in cranial abdo
What does the hepatogastric ligament anchor?
Pylorus and proximal duodenum to porta of the liver
Which ligament doe the common bile duct lie within?
Hepatoduodenal
Why is the lesser curvature difficult to access in surgery?
The short hepatogastric ligament
The arterial blood supply to the stomach originates from?
Celiac artery which is a direct branch from the aorta
What does the celiac artery branch into? (3)
Splenic, hepatic, and left gastric arteries all of which supply the stomach
Which areas should be avoided in surgery?
Unless there is a direct indication to cut along the lesser or greater curvature of the stomach these areas should be avoided to avoid disrupting this blood supply.
What branches run along the lesser curvature of the stomach? (2)
Right and left gastric branches
which vessels which run along the greater curvature of the stomach? (2)
Right and left gastroepiploic vessels
What are the functions of the stomach? (5)
to receive the ingested food;
to act as a reservoir whilst the digestion process begins;
to physically begin the breakdown of food from solid material into chyme;
to begin the digestion of proteins;
to protect against bacterial ingestion.
What is the muscle arrangement of the stomach which allows for mixing of ingesta?
A muscular wall with smooth muscle fibres running in various orientations
What does the body and fundus synthesie/secrete? (3)
Hydrogen chloride acid
pepsinogen
Mucous
What does the pyloric region secrete? (2)
Gastrin
Mucous
What is a small peptide hormone that is also produced by proximal duodenal G cells and it is secreted into the blood. It acts on cells via the cholecystokinin-2 receptor stimulating gastric acid secretion and has trophic effects on the gastric mucosa?
Gastrin
Write down any gastroprotective mechanisms of the stomach.
- Rapid healing
- Surface secretion of mucous and bicarbonate
- Abundant mucosal blood flow
What are the 3 phases of healing for the stomach?
Epithelial restitution:
Replication of surrounding epithelial cells
Acute wound healing:
What does replication of surrounding epithelial cells require?
A Basement membrane
mucosal defects are rapidly sealed by neighbouring cells sliding over the basement membrane to cover the defect. How do cells do this?
This involves cell movement not cell replications; the process begins within minutes of injury.
The viscoelastic properties of mucus and the high concentration of bicarbonate form a barrier by: (2)
neutralising hydrogen ions that diffuse from the gastric lumen;
preventing autodigestion by blocking the diffusion of pepsin across to the mucosal surface.
What is the role of the mucosal blood flow (3)
supplies bicarbonate to the mucosa;
removes inflammatory factors;
removes acid that has back diffused across an overwhelmed or damaged gastric epithelium.
What is important in the maintenance of the gastric mucosal barrier?
Prostaglandin E2
Metabolic and myogenic mechanisms regulate mucosal circulation; exposure to gastric aid results in
Hyperaemia
Why is Prostaglandin E2 important in the maintenance of the gastric mucosal barrier? (2)
- Stimulates bicarbonate secretion
- Enhance mucosal blood flow
“The excellent blood supply means that the stomach heals well.”
Is this statement true or false?
True
“This means that there will be less tension on a surgical wound if the stomach does not become greatly distended in recovery. It also means that it is possible to remove parts of the stomach without compromising function.”
Is this statement true or false?
True
What are the possible consequences of acute and chronic gastric disease because these points must be considered in our perioperative management of patients undergoing gastric surgery? (6)
Debilitation/poor body condition
Dehydration and electrolyte disturbances
Pain/discomfort
Nausea
Abnormal/delayed gastric emptying
Gastric ulceration
Prior to surgery:
How would you approach debilitation/poor BCS?
- Consider using a feeding tube.
Prior to surgery:
How would you approach dehydration, electrolyte disturbances
Administer intravenous fluid therapy, monitor electrolytes, and supplement potassium if appropriate.
Prior to surgery:
How would you approach pain/discomfort?
Analgesia (CARE - (NSAIDs) because of the risk of gastric ulceration, especially in hypovolaemic and/or hypotensive patients)
Remember that opioids can cause nausea and ileus and lidocaine CRI causes nausea as a common side effect; the analgesic effects of these drugs may out-weigh the potential side effects, but these should still be considered.
Prior to surgery:
How would you approach nausea?
Anti-emetic
Prior to surgery:
How would you approach abnormal/delayed gastric emptying?
Prokinetic
Prior to surgery:
How would you approach gastric ulceration?
Use a combination of antacids, proton pump inhibitors and gastric mucosal protectants and avoid NSAIDs.
How long should a patient be starved pre gastric sx?
8-12 hrs
What is the max time juvenille patients should be starved and why?
4 hours because of their limited hepatic glycogen reserves and subsequent increased risk for developing hypoglycaemia
For those patients with gastric outflow obstruction, abnormal gastric motility or delayed gastric emptying there is an increased risk of…? during GA (2)
Regurgitation + aspiration
In cases of gastric outflow obstruction, abnormal gastric motility or delayed gastric emptying, what can be done to reduce risks?
Airway should be secured promptly at induction and an orogastric tube can be passed, once the patient is anaesthetized and their airway is secured, to empty the stomach. The anaesthetist should be vigilant for regurgitation during anaesthesia.
ABx for gastric surgery where blocked/reduced motility?
Antibiotics such as a second-generation cephalosporin should be given intravenously at anaesthetic induction and repeated every 90 minutes throughout surgery.
Why are antibiotics likely unnecessary for simple gastric procedure?
The bacterial load in the stomach is low due to the low gastric pH
If you had a moderate/large amount of leakage of gastric contents intraoperatively how wouldyou approach?
The class of surgery is now contaminated. The abdomen should be lavaged with 200-300ml of saline per kg and this fluid should be removed by suction to reduce the level of contamination so that surgery becomes a clean-contaminated surgery. The antibiotic usage remains as above (i.e. antibiotic given intravenously after induction of anaesthesia, repeated every 90 minutes throughout the duration of surgery and cessation of antibiotics on completion of surgery).”
How much saline is used to flush an abdo?
200-300ml/kg
If you opened the abdomen and the patient had a perforated gastric ulcer, gross contamination of the abdomen with gastric fluid and marked hyperaemia of the peritoneal surfaces how would this affect your antibiotic use
“In this case the patient will have a septic peritonitis and antibiotics should be used at anaesthetic induction, every 90 minutes throughout surgery and should be continued for 5-10 days postoperatively. In this scenario the antibiotics are being used therapeutically.
What class of surgery is a gastrotomy or gastrectomy in the absence of marked inflammation, gastric necrosis, or peritonitis and with limited spillage of gastric contents intra-operatively?
Clean contaminated
What retractors are particularly useful for improving access for cranial abdominal surgery? (2)
Balfour
Gossett
Occasionally for more complicated surgeries (e.g. extensive partial gastrectomy) or when access to the most cranial part of the abdomen, or cardia is required (e.g. hiatal hernia repair). What can be used to access the stomach?
Muscle relaxant
What should be considered to facilitate access to the stomach. Rarely, to facilitate cranial abdominal and caudal thoracic access for gastric surgery the incision can be extended cranial as a..?
Caudal sternotomy
How can you reduce the intraoperative contamination of the abdomen with stomach contents when performing a gastrotomy or gastrectomy? (5)
- Empty the stomach prior to incision (orogastic vs suction)
- Use saline soaked swabs
- Stay sutures (also atraumtic)
- Separate the clean/contaminated and clean parts of the procedure (separate instruments)
- Abdominal lavage
What temp should abdominal lavage be?
37-39
What is the theory behind PDS being unsuitable to suture stomach?
In vitro studies to undergo a rapid and significant loss of tensile strength within an acid environment
PDS is still appropriate to suture stomach, why is this? (Study said not to)
The studies did not consider the likelihood of rapid coverage of the suture with mucosa, partial thickness suture bites and two-layer closures
Which suture has a longer half life in acid environment, so in theory better for stomach closure? (2)
Polyglyconate
poliglecaprone 25
Stomach suturing material size in
Cats/small dogs?
1.5-2 metric
4/0-3/0 USP
Other ways than suturing to close the stomach? (3)
staplers:
Thoraco-abdominal (TA), gastrointestinal anastomosis (GIA)
skin .
Stomach suturing material size in
small/medium dogs?
2 metric
3/0 usp
Stomach suturing material size in
large/giant dogs?
2-3 metric
3/0 - 2/0
How many layers to close stomach?
2
Possible suture patterns to close stomach? (3)
Two simple continuous layers, first closing the mucosa/submucosa (using 1.5-2 metric suture), then closing the seromuscular layer (using 2-3 metric suture)
A first simple appositional layer (e.g. simple continuous) and a second inverting layer (such as Cushing or Lambert pattern)
Two inverting layers.
How to close an extensive gastrectomy or pyloroplasty where there is a risk of causing gastric outflow obstruction?
A simple appositional closure should be performed; either simple interrupted or simple continuous layers can be used,
Which layer MUST be involved in stomach closure?
Submucosa
