Surgery of the Small Intestines

What denotes the change from duodenum to jejunum?

Ileocolic ligament at the duodenal flexure

What is the longest portion of the canine or feline intestines?

jejunum

What portion of the small intestine grossly designated by the presence of the anti-mesenteric artery moving orally from the

cecum?

Ileum

We use ___/___ (closer to the mouth) and ____ (away from the mouth) to describe locations within the intestines

ORAL / ORAD, ABORAL

T/F Small intestinal length is estimated to be 5x the length of the carnivore's trunk

True

The bacterial population within the small intestines increases as it progresses (aborally/orally)

aborally

What are the layers in order of the small intestines?

Serosa, Mucosal Layer, Submucosa, Mucosa

What is known as the strength layer of the intestinal wall and should be included when suturing?

Submucosa

What does the celiac artery split into? (3)

hepatic, splenic and left gastric

arteries (crainial portion)

What portion of the GI tract does the cranial

mesenteric artery associate with?

jejunum and ileum

What artery supplies a large portion of the large intestine?

caudal mesenteric artery

T/F The GI tract has an extensive lymphatic drainage

True

Where is the associated lymph nodes typically found?

base of the mesentery

Mesenteric veins run (parallel/perpendicular) to the mesenteric arteries

parrallel

What are FIVE indications for intestinal surgery?

• Diagnostics (intestinal biopsies)

• Intestinal obstructions

Penetrating abdominal wounds (gunshot wound)

• Fungal / atypical bacterial infections

• Intestinal torsion / volvulus

What are THREE surgical procedures that are normally done for intestinal surgery?

• Biopsy

• Enterotomy

• Resection and anastomosis

What is the most common cause of abdominal sepsis?

Intestinal incision dehiscence after surgical intervention

Specific risk factors can vary from study to study. Generally accepted risks include what? (3)

• Presence of pre-existing peritonitis

• Surgery for removal of GI foreign bodies

T/F Patient's overall health status should be looked at

True

What is something that the literature "doesnt care about and says that there is no difference" but surgeons are worried about it causing dehiscence?

Protein layers (although low protein and low albumin have not been consistently associated with increased risk of intestinal dehiscence)

When doing a GI biopsy, you should ____ intestinal segment to biopsy; "___-___" around

the segment

Isolate, pack-off

How do you isolate intestinal segment to biopsy?

• Occlude the target segment to prevent leakage of intestinal ingesta.

What should be used to occlude a vessel so that it can not be damaged?

• Fingers of an assistant, Doyen forceps, vascular forceps (PDA forceps)

if you use a rubber-clad instruments, what happens and should you use this?

increase of pressure, AVOID

When performing intestinal biopsies, we routinely take __-__ (#) biopsies (duodenum, jejunum (x2) and ileum).

3-4

T/F You will routinely biopsy the colon

False, you dont do this

How do you preform an incisional biopsy (longitudinal)?

• Use _ ___ to make stab incision and lengthen with blade or scissors taking care to avoid the opposite side

of the bowel

• Place ___ __ in the proposed biopsy site

• ___ tissue sample

#11 blade, stay suture, Secure

What type of incision and closure of incisional biopsy?

longitudinal, reverse closure

Why do you make a incisional biopsy this way?

to maintain the lumen diameter

How do you preform a wedge biopsy?

- Place ___ ___ and incise across the intestine on either of the ___ ___ creating a tissue "wedge"

• Carefully free tissue held by stay suture. Avoid

excessive manipulation (thumb forceps) which could damage specimen

• Suture in a ____ ___

• Simple interrupted, appositional

stay suture, stay suture, transverse manner

How do you preform a Longitudinal incision with transverse closure?

- Short ____ incision

• A small slice of the intestinal wall is removed as the biopsy sample.

• Incision closed in a ____ manner with first suture placed in middle of

incision.

longitudinal, transverse

T/F "Longitudinal to transverse" closure reduces narrowing of the intestinal lumen

True

Explain a "Dog-ear" biopsy technique? (2)

- the longitudinal incision is closed transversely, a "dog- ear" is created on either side.

• Trim off the dog ear(s) as biopsy specimens.

What is the technique of a Keyes-type dermal biopsy punch?

Support target segment by pinching mesenteric surface creating a flat aspect for the anti-mesenteric surface

Keyes-type dermal biopsy punch creates a __-___ __biopsy punch

4-8mm

Loss of resistance indicates what type of incision?

full thickness incision

When closing the punch biopsy site, what suture placement is recommend? What must be engaged?

Full-thickness, appositional suture placement, submucosa

What is TYPICALLY used as a pattern for closure of a biopsy?

simple interrupted

What is the suture selection for GI biopsy closure? (2)

• Fine (4-0, 3-0) monofilament, absorbable

• Taper needle (SH or RB-1)

Strength layer of GI tract is the ____

(WE GET IT!!!!)

submucosa

You want the tissue tightness to be "__"

Snug

When making the closure you want to use an appositional closure, why?

minimize manipulation of wound edges with forceps and preserve the blood supply

T/F When closing you should avoid a sharp angle (yellow arrow) as this could result

in an insufficient bite of the submucosa.

True ( slide 10 if confused)

T/F You can use thumb forceps on the intestinal tract

FALSE, do not do this it causes permanent damage

What suture patter is a Partial inverting"

interrupted suture and is intended to invert mucosa?

Gambee suture

T/F Gambee suture are slower & more challenging to place than simple appositional

True

What is the first step of the gambee suture?

- Grasp the needle for a forehand pass, directing the needle through all tissue

layers into the lumen of the intestine. Continue to pass the needle out through the

incision until the needle can be re-grasped

What is the second step of gambee suture?

Re-grasp the needle for a

backhand pass. Re-introduce the needle into the lumen and direct the needle through

the mucosa exiting at the mucosa- submucosa junction. Pull the needle out through the incision and re-grasp the needle

for another backhand pass

What is the third step of gambee suture?

From outside the incision,

continue to hold the needle for a backhand pass. Insert the needle at submucosa-mucosa

junction and pass the needle back through these layers into the lumen. Pull the needle

out through the incision and re-grasp to prepare for a forehand pass.

What is the final step of the Gambee suture?

Re-grasp the needle for a

forehand passage. Pass the needle back through the incision into the lumen & then pass through all layers of the intestines to the serosal surface.

T/F As the suture is tightened, the Gambee

pattern should slightly invert the

mucosa to help with apposition of the

other layers of the intestinal wall

True

What are the indications for a R&A (resection and anastomosis) ?

• Multiple perforations (Linear foreign body, Penetrating injuries)

• Extensive disease (Intussusception, intestinal neoplasia, fungal lesions, ischemia)

When should you do an R&A vs debridement?

When there is HELLA intestine that is f*** so you have to take out alot. If it is a little section then you can debride it

How do you start a R&A? (5)

• Define borders of the resection

• Fenestration mesentery and ligate vessels supplying targeted area

• Isolate the intestinal segment to be resected ("pack off") using moist lap sponges.

• Place clamps on the intestines

• Incise across the bowel

What is the recommended angle at which you incise the bowel?

60-degree angle AWAY from where your are working

What type of suture is needed for an R&A?

• Small diameter, monofilament,

absorbable suture

What needle is used for an R&A?

Taper needle, cutting NOT needed.

What side should you suture first in an R&A?

mesenteric side

T/F You should place the first suture at the 6:00 position and then Place 2 additional interrupted sutures (5:00 and 7:00).

True

Where should you place a suture after you have placed the 3 previous sutures? Why?

• Suture is placed at 12:00 position

• This helps to prevent unequal suturing and creates better apposition

Where should your next suture be placed? Why? (3)

3: 00 (or 9:00)

• Splits distance between mesenteric sutures and anti-mesenteric suture.

• Fill in the space between sutures

• Rotate and repeat this procedure on the opposite side

When completing the procedure of an R&A, how would you complete it?

• Close rent in mesentery (fine absorbable suture) while avoiding injury to adjacent vessels

• Leak test site

• Consider additional support

__-__-__` device generally too large for small animal surgery

End-to end anastomosis

Stapled R&A technique requires what type of incisions ?

to triangulate the incisions

What is the most common Stapled R&A technique?

Two stage

What is a Two stage Functional end-end anastomosis?

Combination of GIA stapler and TA stapler

How is the site of anastomosis created?

by apposing the adjacent portions of intestines

Mesentery should be ___(angle)__ to the intestinal segments

90

The portion to be resected is isolated by a ___-_____ ____ placed across both sides of the

intestines

non- crushing clamp

The GIA is used to make a Single-stage, stapled

anastomosis. How does it do this?

- A stab incision is made into

the lumen of the adjacent

intestinal segments and the GIA is inserted into each lumen and closed

- The GIA is "fired" placing two staple lines joining the adjacent intestinal segments

TA stapler is used to seal the top of the anastomosis. How is it used?

- The stapler is placed proximal to the stab incisions and the GIA staple lines are slightly offset to minimal interference when stapling wit the TA

- The looped portion of the

intestines (portion to be

resected) is removed.

What is used at the site to test for leaks?

before a final lavage with warm saline & closure

What do GI foreign bodies increase the risk of?

dehiscence after foreign body removal

What is is repeatedly found to be one of the greatest risk factor for post-operative intestinal dehiscence resulting in abdominal sepsis?

Intestinal surgery for the removal of an intestinal foreign

body

Foreign body removal: where do you incise first?

Try to place the incision in an area of "normal, healthy tissue"

What is the first step that you should do when removing a FB?

try to advance further

aborally

What is the last choice for removing a FB?

incision directly over the foreign body

If the majority of a foreign body is in the stomach or proximal duodenum, what do you do?

• Perform gastrotomy

• Can the foreign body be "milked" back into the stomach? Perform gastrotomy only.

T/F You should DOUBLE CHECK check the involved intestines after removal to ensure there are no perforations

True

What are the TWO components of a linear FB?

• Orad anchor point

• Length of material that is pulled aborally through

the GI tract.

What does the linear FB cause to the intestines?

plicates

How do you remove the linear FB? (2)

• Identify the location of the anchor

• Release the anchor and carefully extract the linear FB

What is the most common spot for an anchor in dogs and cats?

Stomach in dogs, base of tongue in cats

T/F DO NOT place the foreign material under

significant tension when removing or it could

perforate the intestine

True

T/F Actual incision for a linear FB is same as biopsy or enterotomy.

True

How do you estimate where to incise to minimize # of enterotomies required?

• Apply gentle traction to the linear FB

Youre a silly little guy and you decide to YANK THAT *** when dealing with the linear FB. What may be something that you just did?

made the linear FB to cut through the intestinal wall (:/)

When faced with significant intestinal plication and trauma from a linear FB, you need to consider whether what surgey may be a more appropriate treatment option

intestinal resection (and anastomosis

What should you do if the foreign body has made it to the colon?

leave alone (allow to pass) or manipulate towards distal colon and remove.

T/F Incisions in the colon are common so if you need to do them it is okay and shouldnt be avoid

False, just avoid them

How do you do a Catheter-assisted linear foreign body removal?

• Make a small enterotomy incision at one end of the foreign body.

• Tie the linear foreign body to the tip of the catheter

• Insert the catheter into the intestinal lumen.

• Aim the catheter against the direction of the foreign body

• Gently milk the catheter within the lumen.

• Remove the catheter from a second enterotomy incision, out of a gastrotomy incision or from the anus (assistant!)

• Go back and recheck the intestines for evidence of necrotic areas or perforation

What is something that you may need to consider when doing an Enterotomy closure?

Leak testing

How do you preform a leak test?

Inject 10 -12 mL of saline in a 10 cm segment (occluded with Doyen clamp) generated 20 cm pressure

What is the goal of a leak test?

providing adequate pressure to

identify leaks

What clamp has providing adequate pressure to identify leaks ?

Doyen clamps

If a leak is discovered, what are THREE things that you should do to fix this?

• Add additional sutures

• Omental or serosal patch

• Remove, debride and re-suture

closure

What is something that may lead to a false sense of security with a leak? Why?

Blood clots and fibrin can

temporarily seal the incision

site

What is something that involves wrapping the omentum over/around intestinal incisions? What does it help with?

Omental wrap (sorry this is dumb), GI healing

What is better than an omental wrap bc it helps with better support of the intestinal incision?

Serosal patch

T/F The omental wrap helps provides a greater seal against leakage.

Fasle, sersosal patch