Surgery of the stomach, SI, LI, rectum and anus

What is a hiatal hernia?

Herniation of cardia of stomach through oesophageal hiatus

• May present as gastrooesophageal intussusception

How are hiatal hernia graded?

1-4 based on location/ extent

How are hiatal hernia treated?

Surgically if persistent

• Suture reduction of hiatus

• Oesophagopexy

• Left fundic gastropexy

When is a gastrotomy usually performed?

Usually for FB removal but can be exploratory

Outline how a gastrotomy is performed?

• Ventral midline coeliotomy.

• Pack off stomach and stabilise the avascular area between the greater and lesser curvatures with 3-4 stay sutures.

• Incise stomach in this area (mucosa is quite tough) and explore

How is a gastrotomy closed?

1 or 2 layer closure

• First layer in mucosa or submucosa (contiunous or interrupted / Cushing or lembert)

• Second layer in serosa/ muscularis/ submucosa (Cushing or lembert)

When would you perform a partial gastrectomy?

• Necrosis (e.g.- in GDV)

• Neoplasia

• ulceration

What are the different techniques for partial gastrectomy?

• Invagination of tissues

  • Serosa apposed, necrotic tissue allowed to slough

• Sharp excision

• Surgical staplers

What dogs are predisposed to GDV?

• Purebred large / giant dogs

  • Gordon setter, standard poodle, Weimeraner, Irish setter, great Dane and St. Bernard at greatest risk

• Particularly with inc thoracic depth:width ratio

• First degree relative with GDV

• Fearful/ aggressive temperament

• Feeding few meals, eating rapidly

What happens in a GDV

• Rotation of stomach (more common clockwise)

  • 180° most common but anywhere from 90-360°

• Pylorus moves to left and fundus to right (rotation along long axis)

• Oesophagus twists where enters stomach

• Stretching and thinning of pylorus occluding outflow as well, causing dilation and other physiological effects

Explain the physiological effects of GDV

• Haemodynamic effects

  • Red abdo blood flow and venous return-> cardiogenic shock-> splenic congestion

• Resp dysfunction

  • Inc pressure limits diaphragmatic movement

• Cardiac dysfucntion

  • Red perfusion

  • Myocardial depressant factor released causing myocardial ischaemia

  • Necrosis and arrythmias

• Gastric wall necrosis

  • Vessels compressed reduced perfusion

• Bacterial translocation

  • Sepsis, toxic shock

• Reperfusion injury when corrected

What is this radiograph showing?

GDV

• Typical reverse C shape

What would you see on lab tests with GDV?

Haematology: haemoconcentration, stress leucogram, thrombocytopaenia.

Biochem: inc ALT and bilirubin, increased BUN and creatinine due to hypotension and various electrolyte abnormalities.

• Plasma lactate may be helpful inpredicting prognosis and the presence of gastric necrosis

What are your two immediate priorities with a GDV treatment?

• Fluid therapy

• Decompression of stomach

What do all GDV cases require to prevent reoccurence?

Gastropexy

NB- won't prevent tmpany/dilation

How would you admin fluids for GDV?

• Shock therapy

  • Short wide cannulae, 2 if required (never in HL bc caudal to venous return)

How is decompression of the stomach performed?

• Stomach tube

  • Done conscious

  • Pass with aid of lub and mouth gag

  • Turn to aid passage

  • Cover end on removal to stop fluid spillage and aspiration

• Needle paracentesis

  • 14-16g needle via flank

  • ID gas filled fundus by percussion

• Temporary gastrotomy

How is a temporary gastrotomy performed for a GDV?

• LA via flank

• 5cm incision caudal and parallel to costal arch

• Dissect through abdo wall to stomach

• Stay suture and decompress with needle then stab incision

• Suture gastric and seroa to subcut

• Suture mucosa to skin

How are stay sutures used to manipulate tissue?

• Assistant hold them and manipulate

• Hold one with your non dominant hand

• Clip to drapes/ wind them around a retractor if don't have assistant

How does a gastropexy work?

• Fixes pylorus to right abdo wall

• Reposition stomach by gentle traction on pylorus first

Explain two techniques of gastropexy

• Incisional gastropexy

  • Longitudinal incision in pyloric antrum

  • Transverse incision just caudal to last rib

  • Stay suture at each end of first incision, tie suture and then appose the margins of wound (see notes)

    

• Tube gastropexy

  • Foley catheter through stab incision

  • Purse string suture in pyloric antrum (see notes)

    

Should splenectomy be performed with a GDV surgery?

• If not thrombi and no splenic torsion not indicated

• Congestion generally resolves when stomach repositioned

• Don't remove unless have to bc inc surgical time

When do you have to perform a partial gastrectomy in a GDV surgery?

• Presence of gastric necrosis

• Assess stomach wall viability

  • Colour

  • Bleeding

  • Pulses

  • Thinning= necrosis

What are the post op considerations to make for GDV?

• Fluids

• Monitor ECG (VPCs common)

• Monitor electrolyes

• Nil by mouth 24-48hrs then water and small amounts of food

• Gastric mucosal protectants

  • Sucralfate, Antacids

• Metoclopramide if vomiting (delay feeding)

• Small freq meals and avoid exercise after meals

What are the possible causes of gastric outflow obstruction

• Neoplasia

• Pyloric stenosis

• Hypertrophic gastritis

• Pyloric muscular hypertrophy/dysfunction

How are gastric outflow obstructions treated?

• Surgically

  • Several pyloroplasty procedures (widens diameter of pylorus)

What are Billroth I (gastroduodenostomy) and Billroth II (gastrojejunostomy) procedures?

Allow resection of large amount of distal stomach and pylorus (e.g.- in neoplasia)

• Choice based on amount of tissue to be resected and resulting tension

What are they doing here?

• Occluding the lumen before incision to prevent leakage of the GI contents

• Longitudinal incision - least vascular and least likely to cause stricture

How do you deal with joining these intestines?

• Left smaller diameter - cut on the antemesenteric border to increase the diameter

• Right everting slightly - can trim this

When you’re clamping off the intestinal lumen to do an enterectomy, which set of clamps (crushing or non-crushing) should you put on first?

• Crushing clamps first then non curshing

  • Sets boundaries for resection

  • Ensure where you are cutting is in viable tissue

  • Minimises time that intestine you're not resecting is clamped for

What are the features of linear foreign bodies

• More common in cats

• Problem when fixed proximally

• Concertina of intestines

How do you treat a linear foreign body?

• Conservative- cut it

  • If FB under tongue, no evidence of peritonitis then FB will often past ok in 3d

• Surgery if FB not fixed at tongue or signs of peritonitis

  • Mutliple incisions starting at distal end

What is intussception usually secondary to?

Something causing hypermotility (e.g.- diarrhoea, high parasite burden)

• Can happen at ileocolic junction may progress and protrude through anus

How can you treat intussusception?

• Sometimes can be done manually

• If not have to perform enterectomy