Lesson 111 - Abdominal Surgery of the Cow

Name the 3 methods of flank anesthesia in cattle?

1. paravertebral

2. inverted L

3. line

What are the pros to performing a line block?

fast and easy

What are the cons to a line block?

1. can delay healing

2. distort the incision

3. doesn't block a large area

What are the pros to an inverted L block?

1. larger area blocked

2. away from surgery site

3. no incision distortion

What are the cons to an inverted L block?

1. more anesthetic needed

2. multiple pokes

3. need anatomy knowledge

What are the pros to the paravertebral block?

1. more precise blocking

2. larger area

3. less drug needed

4. no trauma to incision

What are the cons to the paravertebral block?

1. need to know anatomy

2. blocking wrong area

3. may react to block and kick

4. scoliosis

5. can become recumbent if block too far down

What are risk factors for displaced abomasum?

1. mastitis, retained fetal membranes

2. abomasal ulcer, hardware disease

3. recently calved, final month of gestation

4. ketosis, milk fever, low roughage content

5. stress, change of ration

6. holstein cow

7. estrus

What is the prevalence of displaced abomasum?

1. left displaced: 90%

2. right displaced: 10%

What are the predispositions for displaced abomasum?

1. guernsey, holstein-friesian, ayrshire breeds

2. large abdominal cavity

3. springtime with lush grass

What are factors that make displaced abomasum more common in the peripartum period?

1. 91% within 6 weeks peripartum

2. high grain diet/low roughage

3. reduced exercise

4. secondary disease

What secondary disease from peripartum are associated with abomasal displacement?

1. hypocalcemia

2. mastitis

3. metritis

4. retained placenta

5. ketosis

6. fatty liver

What are clinical signs for a left displaced abomasum?

1. TPR WNL

2. reduced milk production

3. anorexia

4. left caudal rib sprung

5. weight loss

6. reduced fecal output

7. chronic dull gaunt appearance

What can happen secondary to left displaced abomasum?

ketosis

How do we diagnose left displaced abomasum?

1. ping on auscultation

2. liptak test with pH

What are the clinical signs of a right displaced abomasum?

similar to LDA

What are the clinical signs of a right abomasum volvulus?

1. colic

2. hypochloremia

3. hypokalemia

4. metabolic alkalosis

How do we diagnose right displaced abomasum?

1. ping on auscultation typically around 9-10th rib

2. rectal examination

A venous blood gas of a cow with a DA would show a pH of?

7.45

What are the methods to treat a displaced abomasum?

1. roll and toggle or tack

2. right sided ometopexy

3. right sided pyloropexy

4. left side abomasopexy

5. right paramedian abomasopexy

6. laparoscopic abomasopexy

Which of the following options represents a conservative approach to treating a LDA?

roll and toggle

What are the conservative treatments for displaced abomasum?

1. cast and roll for LDA

2. blind tack and toggle

What is involved with the cast and roll?

1. cast on right

2. roll over back clockwise

3. recurrence common

What is the success rate for blind tack and toggle?

similar to surgical procedures; 85-90%

What type of case do we use conservative treatments for?

fresh displaced abomasum with no adhesions

What is another term for blind tack/toggle?

abomasopexy

What are the contraindications for blind tack/toggle?

1. respiratory compromise

2. no ping

3. concurrent abomasal disease

What are the steps to a blind tack/toggle?

1. first clip and prep cranioventral abdomen

2. identify milk well and vein

3. cast and roll into dorsal recumbency

4. located abomasum by ping in right cranioventral abdomen

5. 1-2 sutures through skin and abomasum (tack) OR

6. use cannula and trochar to place toggle pin into abomasum

How do you confirm that your cannula is in the correct place for abomasal displacement toggle?

remove trochar and release of gas odor occurs and check pH of gas - should be acidic

What are the pros to roll and toggle?

1. avoid surgery

2. quick to do

3. quicker recovery

4. cheap

5. enter milking herd sooner

What are the cons to roll and toggle?

1. can't be certain that you entered the abomasum

2. may trap intestine between the toggles

3. risk of rolling the cow and splitting the pelvis

4. leakage of gut contents may lead to peritonitis

5. abomasal rupture

6. fistual formation

7. detachment

What abomasal surgery do we use a standing left flank approach?

abomasopexy for a left displaced abomasum

What abomasal surgery do we use a standing right glank approach?

1. abomasopexy for a right displaced abomasum or torsion

2. omentopexy or pyloropexy for LDA and RDA

What abomasal surgery do we have the cow recumbent for?

paramedian LDA abomasopexy

What laparotomy has the highest risk of wound infections?

ventral paramedian

What are you going to do pre-surgery?

1. analgesia like flunixin IV

2. broad spectrum antimicrobials if needed

3. fluids IV

4. sedation if needed

Why do we not give oral fluids before surgery?

don't want the stomach any heavier so we can maneuver it easier

What are the steps to an incision for a flank laparotomy?

1. middle of paralumbar fossa

2. 3-5cm distal to transverse process

3. 20-25cm long

4. through skin and subcutaneous tissues

5. extend vertical incision through external and internal obliques

6. elevate aponeurosis of transverse abdominus with forceps to make small incision

What do you want to avoid when doing your incision on the left side?

inadvertent incision into rumen

What organs can you examine with a left approach?

1. rumen

2. reticulum

3. spleen

4. left kidney

5. caudate lobe of liver

6. gallbladder

7. diaphragm

8. omental bursa contents

What organs can you examine with a right approach?

1. duodenum

2. pylorum

3. abomasum

4. small intestine

5. cecum

6. colon

7. kidneys

8. liver and gallbladder

9. diaphragm

What are the layers we close for a flank laparotomy procedure?

1. transverse abdominus +/- peritoneum

2. internal and external abdominal oblique

3. skin

How do we close the transverse abdominus +/- peritoneum?

simple continuous ventral to dorsal with 2/3 chromic catgut

How do we close the internal and external abdominal obliques?

simple continuous with 3 chromic catgut anchored to deeper suture to reduce dead space

How do we close the skin?

ford interlocking with heavy monofilament with 2-3 interrupted at ventral aspect for drainage

What do we give post-op?

1. NSAIDs

2. antibiotics

3. suture removal 2-3 weeks

What are the steps for a left flank abomasopexy?

1. continuous interlocking suture in greater curvature

2. decompress gas and push abomasum ventrally

3. pass sutures through right paramedian body wall

4. 10cm right of umbilicus and 10cm cranial to umbilicus

What are the pros to the left flank abomasopexy?

1. abomasum in natural position

2. less rummaging in cow

3. adhesions and ulcerations can be directly visualized

4. exploratory rumenotomy can be performed if indicated

What are the cons to the left flank abomasopexy?

1. need long arms

2. causes localized peritonitis

3. suture may detach

4. be way not to puncture milk vein

What is the procedure for LDA with a right flank approach?

1. deflate abomasum in situ

2. replace in correct position

3. retract omentum until pyrlorus visualized

4. anchor omentum or pylorus to internal muscle

Which flank approach can we examine the liver if we suspect hepatic lipidosis?

right flank approach

What are the pros to the right flank approach?

1. better than ventral paramedian in severely compromised cow

2. no second person/long arm necessary

3. less of anchoring procedure performed blindly

4. easier to remove fluid without contamination

5. only option if abomasal volvulus

What are the cons to an omentopexy?

may detach especially in animals with fat mobilization

What are the cons to an pyloropexy?

may cause pyloric outflow obstruction

What is a pro to the pyloropexy?

less likely to detach

What are the steps for an abomasopexy with ventral paramedian approach?

1. sedation and cast

2. dorsal recumbency

3. make incision 10cm right and cranial of umbilicus

4. anchor greater curvature to peritoneum/internal rectus sheath

5. incorporate in first layer of closure with simple continuous

6. close external rectus sheath with horizontal mattress

What are the pros to the ventral paramedian approach?

1. abomasum in natural position

2. instantaneous repositioning

3. able to examine abomasum for ulceration

4. strong adhesion formation

What are the cons to the ventral paramedian approach?

1. casting requires man-power

2. risk of regurgitation

3. cannot explore rest of abdomen

4. incisional infection

What are the steps for RDA with a right flank approach?

1. decompress gas

2. drain fluid

3. place stomach tube through purse-string suture

4. omentopexy/pyloropexy as if doing an LDA

What methods do we have for an LDA?

1. standing left flank abomasopexy

2. ventral paramedian abomasopexy

3. blind tack/toggle abomasopexy

4. standing right flank omentopexy/pyloropexy

What methods do we have for an RDA?

1. standing right flank abomasopexy

2. standing right flank ometopexy/pyloropexy

What is the post-op management for a displaced abomasum?

1. NSAIDs

2. antibiotics

3. treat concomitant disease

4. neostigmine may help but not in milking cows

5. good quality roughage

What is the post-op management for an abomasal volvulus?

1. NSAIDs

2. antibiotics

3. fluid therapy

4. transfaunation

5. roughage

What approach is used for a rumenotomy/

standing left flank approach

What are the indications for a rumenotomy?

1. foreign bodies

2. rumen overload

3. rumen impaction

If a cow is recumbent, how do we approach a rumenotomy?

sternal or right lateral recumbency with a left flank approach

What are the steps to a rumenotomy?

1. anchor rumen to body wall

2. incise rumen

3. close with inverting pattern

4. irrigate prior to removal of fixation sutures/device

How do we anchor the rumen to the body wall during a rumenotomy?

1. continuous inverting suture pattern

2. rumen board/ring

What is the key aim when performing a rumenotomy?

no rumen contents into abdomen

What approaches do we use for small intestinal conditions?

1. ideally a standing right flank approach

2. might have to perform on recumbent cow

What are the clinical signs of small intestine conditions?

1. depressed

2. drop in milk production

3. caudal abdominal pain

4. increased heart rate

5. decreased rumen activity

6. anorexia

7. ileus

8. reduced fecal output

What signs are seen with ileus from small intestinal disease?

1. low/bilateral distention

2. fluid wave succussion

3. hypochloremic metabolic alkalosis

What signs are seen with small intestinal diseases in calves?

1. similar to adults

2. hard to differentiate between enteritis

3. decline more rapidly

4. bloat

5. colic

What are the differentials for small intestinal disease?

1. intussusception

2. volvulus

What are the causes of intussusception?

1. viral enteritis

2. diet alteration

3. polyp/nodule

Where do adult cows get intussusception?

distal jejunum/ileum

Where do calves get intussusception?

throughout small intestine

What is seen with a mesenteric root volvulus?

1. acute abdomen

2. more severe signs than intussusception

3. can't pass orogastric tube

4. soon die unless surgery

For what gastrointestinal surgery is performing a recumbent laparotomy recommended in an adult cow?

small intestinal strangulation

How do we diagnose small intestinal disease?

1. clinical signs

2. ultrasound especially in calves

3. rectal exam

4. exploratory laparotomy

How do we treat small intestinal disease?

1. stabilize first

2. right flank celiotomy

3. resection and anastomosis

What approach do we use for cecal dilation/displacement?

standing right flank approach

What are causes of cecal dilation?

1. hypocalcemia

2. elevated VFA production

What are risk factors for cecal dilation?

milking cows

What are the clinical signs for cecal dilation?

1. drop in milk yield

2. reduced appetite

3. discrete clinical signs

4. reduced fecal output

5. distention of right paralumbar fossa

6. ping on percussion of right paralumbar fossa

How do we diagnose cecal dilation?

1. ping on right side

2. rectal exam

3. cecum palpable on rectal

4. if can't decompress cecum then most likely torsion

What is the treatment for cecal dilation/torsion?

right flank celiotomy and tyhplotomy

What are the complications with cecal dilation?

1. septic peritonitis

2. persistent motility disorder recurrence 10-22%

How do you treat persistent motility disorder with cecum?

cecal amputation/typhlectomy, but not likely performed in cows

What are the indications for a typhlotomy?

cecal dilation, torsion, dislocation

What is the procedure for a typhlotomy?

1. decompression of gas filled viscus

2. exteriorize cecum

3. isolate apex and incise most ventral location

4. close in 2 layers

How do we close the second layer of the cecum?

using inverting pattern like cushing, lembert, or utrecht

What approach do we use for colon conditions?

1. ideally standing right flank approach

2. may have to perform on recumbent cow

What is the etiology of atresia coli?

1. mid spiral colon most frequent

2. early manual pregnancy testing

What are the clinical signs for atresia coli?

1. normal parameters for first 48 hours of life

2. bloated/abdominal distention

3. no fecal output

4. distended loops of intestines

What are the surgical options for atresia coli?

intestinal resection and anastomosis

What is the prognosis with intestinal resection and anastomosis for atresia coli?

guarded to poor

What cows more commonly have atresia ani?

beef > dairy, also sheep

What are the clinical signs of atresia ani?

1. lack of tail possible

2. abnormal urinary genital tract may be present

3. fistula between rectum and repro tract

4. rarely systemic symptoms if fistula present

How do we treat atresia ani?

1. surgery

2. electrolyte and fluid replacement

3. consider anatomical viability

4. consider ethical complications