Small Animal surgery Exam 2

indications for celiotomy/ laparotomy

• investigation

• surgical correction of disease

• supportive or prophylactic procedures

indications for emergency celiotomy

• uncontrollable hemorrhage or inability to stabilize patient

• free air on radiographs

• penetrating abdominal injury (missile wounds, bite wounds)

• bacteria, plant material, predominantly toxic neutrophils on cytology

• bilirubin

What is the length of the incision for exploratory celiotomy according the the lecture (even though he said it is rare that you will ever go this far)?

xyphoid to pubis

when doing the four corner drape, what is important to add for adequate aseptic technique?

add extra towel clamps around the patients (not just the typical 4)

what is the saying for draping for an exploratory celiotomy?

“clip wide, drape narrow”

where should the drapes sit on the patient when preforming an exploratory celiotomy?

inside the nipple line on each side

if using cautery during your exploratory celiotomy, when should the ground plates be placed?

before the patient is draped

what are surgical approaches to a celiotomy?

• ventral midline

• paramedian

• paracostal

• flank

• mid-line/ parapreputial in males

what is the most common reason a paramedian approach is done for celiotomy?

missed ventral midline approach

why should paramedian approach be avoided?

you cut into the muscle (more painful to the patient)

for a paracostal incision, where should the incision be made?

parallel to last rib

what species has a wider, more transparent linea alba?

cats

excessive dissection following the ventral midline approach to reach the linea alba can result in ______

dead space

list the organs/ structures within the cranial abdomen (6)

• diaphragm

• esophageal hiatus

• liver

• gall bladder

• stomach

• pancreas (left lobe)

list the organs/ structures within the right abdomen (6)

• duodenum

• pancreas (right lobe)

• right adrenal

• right kidney

• right ureter

• right ovary/ uterine horn

list the organs/ structures within the left abdomen (6)

• descending colon

• spleen

• left kidney

• left adrenal

• left ovary/ uterine horn

• left ureter

list the organs/ structures within the central abdomen (4)

• ascending colon

• ileum

• jejunum

• mesenteric nodes

list the organs/ structures within the caudal abdomen (4)

• duodenocolic ligament

• urinary bladder

• uterine body

• prostate

indications for a warm lavage following an exploratory celiotomy

• contaminated surgeries

• perforated bowel

• diffuse peritonitis

• hypothermic patients

what is the minimum volume for a warm saline lavage following exploratory celiotomy?

200-300 mL/kg

what are the 3 layers for closure for exploratory celiotomy?

1. external rectus fascia

2. subcutaneous tissue

3. skin

what is the holding layer for abdominal closures?

external rectus fascia

for the external rectus sheath closure following abdominal procedures, what suture should be used?

• intermediate to long lasting absorbable suture (PDS or PGA)

• non-absorbable if delayed healing is expected (polypropylene or monofilament nylon)

how far away should your bites me in the fascia closure following an abdominal surgery?

5 mm (bites that are less strength)

what are the steps that can be used to evaluate the closure of the abdomen?

1. lift up the suture bites = whole body wall should move

2. place finger in incision line and lift up

3. try to insert tips of hemostats between sutures

for subcutaneous closure, what is a technique that can be used to decrease dead space in an abdominal closure?

interrupted sutures with bites into underlying fascia

what is the “bite pattern” for “burying the knot”?

deep to superficial → superficial to deep

define eviseration

dehiscence with the viscera hanging out of the cavity due to weakness of body wall closure

list the surgical diseases of the stomach

• gastric FB

• benign gastric outflow obstruction → non-neoplastic pyloric disease

• gastric ulceration/ erosion

• gastric neoplasia

• oomycosis

• GDV

oomycosis in the stomach will minimuc what other disease?

gastric adenocarcinoma

what is the most common gastric neoplasm?

gastric adenocarcinoma

what are common gastric FBs in cats?

trichobezoars, needle, string

what are medical conditions that predispose a patient to PICA?

• behavioral

• pancreatic exocrine insufficiency

• hepatic encephalopathy

• iron deficiency

acidosis on bloodwork of a patient with a suspected gastric FB indicates

dehydration

alkalosis on bloodwork of a patient with a suspected gastric FB indicates

vomiting gastric secretions

list the different FB removal options

• conserative

• endoscopy

• gastrotomy

• induce emesis

what artery supplies the lesser curvature of the stomach?

left gastric

what artery supplies the greater curvature of the stomach?

lest gastroepiploic

what is the holding layer of the stomach?

submucosa

serosa-to-serosa contact in the stomach closure enhances

formation of fibrin seal

the closure of the stomach should be __layer(s)

2

the first layer closure of the stomach should be ______ while the second one is _______

appositional, inverting

inverting patterns that can be used on the stomach

lembert or cushing

when might it be appropriate to do a single layer closure in the stomach?

when there is insult in the pyloric region

characteristics of congenital pyloric stenosis

• hypertrophy of circular muscles

• brachiocephalic breeds <1 year of age

• siamese cats (rare)

• etiology: excess gastrin??

• signs start at weaning (when diet is switch from milk to a more solid diet)

what is the characteristic radiograph for a case of congenital pyloric stenosis?

“beak”/ “apple core”

what is the diagnostic of choice for a case of congenitial pyloric stenosis?

ultrasound

what are the 2 techniques for treatment of congenital pyloric stenosis?

• Fredet-Ramstedt pyloromyotomy

• Heineke-Mikulicz pyloroplasty

describe Fredet-Ramstedt pyloromyotomy

seromuscular layers

• quick and easy

• no lumen exposure for inspection/ biopsy

• for congenitial only!

• less chance of contamination

• stenosis may reoccur

describe Heineke-Mikulicz pyloroplasty

full thickness

• limited exposure of pyloric mucosa for biopsy

• reoccurence is less likely

• more potential for contamination

• acquired stenosis

acquired pyloric stenosis is more common in

• males » females

• middle-aged » older

• small breeds » larger

grade of pyloric stenosis is done using

ultrasound

list the grades of pyloric gastropathy

grade 1: muscular hypertrophy

grade 2: muscular and mucosal hypertrophy

grade 3: mucosal hyperplasia + muscular and submucosal inflammation

what are the treatment methods for chonric hypertrophic pyloric gastropathy

• transverse pyloroplasty

• Y-U pyloroplasty

• billroth 1

• biopsy

describe the Y-U pyloroplasty technique

• transposes antral wall to pyloric region

• creates a wider pylorus

• shorten gastric emptying time

• allows mucosal resection

• transection of the gastrohepatic ligament provides better exposure

• avoid hepatoduodenal ligament = damage to the common bile duct

billroth technique is can described as

pylorectomy with gastroduedenostomy

when would billroth 1 technique be indicated?

severe outflow obstruction with grade 3 pathology

advantages to billroth 1 pylorectomy technique

• abnormal tissue completely removed

• larger increase in gastric outflow

disadvantages to billroth 1 pylorectomy technique

• technically difficult

• longer procedure

• increased risk of leakage

describe gastric adenocarcinoma

• 60-70% of gastric neoplasias in dogs

  • rough-coated collies, staffordshire terriers, belgian shepherds

• males » females

• average age = 7-10 years

• pyloric antrum, lesser curvature

• metastasis is common (70-80%)

  • regional LNs, liver and lung

to diagnose gastric adenocarcinoma, what test would you use?

endoscopy

list the treatments for gastric adenocarcinoma

• aggressive surgical excision (>5 cm margins, removal of regional LN for biopsy and staging)

• palliative bypass procedure for non-resectable obstructive lesions

• chemotherapy?

• gastrectomy

• billroth 1 & 2

indications for a gastrectomy

• neoplasia

• ischemic injury (GDV)

• ulcer

• trauma

define billroth II

partial gastrectomy with gastrojejunostomy

indication for billroth II technique

when resection of stomach is so proximal to limit end to end anastomosis

Billroth II complications

• alkaline gastritis: bile and pancreatic secretions flow into stomach

• “blind loop” syndrome: gastric contents move orally and putrefy

• marginal ulceration: ulceration of jejunal mucosa- not used to seeing acidic contents

what surgical gastrectomy technique can be used to avoid alkaline reflux gastritis and decreases likelihood of blind loop syndrome?

Roux-en-Y anastomosis

characteristics of gastric leiomyosarcoma

• usually middle-aged (~7 years)

• smooth muscle origin

• more common in cardia vs. pylorus regions

• can be single or multiple

• median survival time- 21 months

characteristics of gastric leiomyosarcoma

• very slow growing

• often an incidental finding

• often in older patients > 15 years

• can be submucosal resection

• may cause gastric outflow signs

causative organism for oomycosis (pythiosis)

Pythium insidiosum

describe pythiosis

• primarily in southeastern US

• seen in fall and winter months

• organism lives in aquatic environment

• affected young large breed working dogs

• rapid growth rate and extensive nature

• infiltrates submucosa and muscularis layers of stomach and small intestines

pythiosis treatment

• surgical excision with 3-4 cm borders

• combined with medical treatment (itraconazole and terbinafine + immunotherapy)

• monitor for recurrence with ELISA 2-3 months post-op

• studies using b-glucan synthesis inhibitors = caspofungin and anidulafungin

• prognosis: guarded to poor

definition of dilatation (dilation)

distension of the stomach with fluid, food, and or gas

definition of dilatation-volvulus

enlargement of the stomach associated with rotation on its mesenteric axis

stomach distension is caused by

air, fluid, food, and a frothy mucoid substrate

gastric dilatation and volvulus is characterized by

accumulation of gas in the stomach and functional/ mechanical pyloric outflow obstruction

GDV is usually a _______ rotation

clockwise

what is the #1 breed predisposed to GDV?

great dane

what are the 3 main events of GDV in the pathophysiology?

• thoracic and diaphragmatic impingement

• decrease caudal vena cava and portal vein blood flow

• gastric ischemia

what are the effects of GDV?

• myocardial ischemia, cardiac arrhythmias

• obstructive shock → reperfusion injury

  • kidneys, heart, pancreas, stomach, small intestine

• SIRS

• DIC

list the clinical signs associated with GDV

• ACUTE

• abdominal distension

• abdominal pain

• retching, vomiting

• hypersalivation

• restlessness/ lateral recumbency

• panting, heavy breathing

• coughing

• collapse

describe the compensatory presentation of GDV

• tachypnea

• tachycardia

• bounding pulses

• prolonged CRT

describe non-compensatory presentation of GDV

• MM injected

• weak, laterally recumbent

initial stabilization of GDV includes

• aggressive fluid therapy

• ± oxygen support

• blood pressure and EKG monitoring

pros and cons to orogastric tube ± sedation for gastric decompression

pro: very effective

con: usually needs sedation

pros and cons to nasogastric tube for gastric decompression

pro: least invasive, can be used for continued drainage if there’s a delay between stabilization and surgery

con: slowest method

pros and cons to trocharization then orogastric/ nasogastric tube for gastric decompression

pro: fastest method

con: “highest complication rate”

what are the parameters for measurement for orogastric tube?

nose to the xyphoid process

list the complications of gastrocentesis (although rare)

• peritoneal contamination

• splenic puncture

CBC of a patient with GDV would show

thrombocytopenia if DIC

chemistry of a patient with GDV would show

hypokalemia

coagulation tests of a patient with GDV would show

• prolonged PT, ± prolonged apTT

metabolic aklalosis in GDV patients is caused by

sequestration of hydrogen ions in the gastric lumens

respiratory acidosis in GDV patients is caused by

hypoventilation

radiographs of a GDV patient should be taken

after stabilization

what radiographic view is used to diagnose a GDV?

right lateral

a VD radiographic view of a GDV patient can predispose to

reflux or aspiration

what is the characteristic view of a radiograph for a GDV patient?

double bubble

list the benefits of early surgery for GDV patients

• gastric repositioning improves blood flow

• surgery may be completed before onset of arrhythmias

what are the 3 primary objectives to surgical management of GDV?

1. reposition the stomach

2. assess the severity of ischemic injury

3. perform a permanent gastropexy