Exam 3: Surgical Management of Forestomach Disease

what determines the treatment of traumatic reticuloperitonitis

• stage of disease and presence of sequella

• value of the animal

• diagnostic and surgical facilities available

treatment of acute localized peritonitis

• systemic antibiotics

• reticular magnets

• stall confinement

treatment optins for chronic localized peritonitis and perireticular abscessation

• left paralumbar fossa exploratory lapraotomy

• rumenotomy 

• right paramedian exploratory celiotomy 

left paralumbar exploratory 

• performed standing with local or regional anesthesia 

• only partial abdominal exploration possible 

• excellent access to reticular regio 

• exploration should proceed from caudal abdomen to reticular area 

• DO NOT disrupt fibrous adhesions 

rumenotomy

• performed through a rumenotomy board or directly suturing rumen to skin

• rumen contents removed

• exploration of reticulum and removal of foreign body

• periretiruclar abscesses can be aspriated through a 14g needle and tubing

• if confirmed and tightly adhered, abscesses are drained into reticulum

• complete exploration through the rumen wall and reticuloomasal orifice

closure of rumenotomy 

• double layer, inverting suture pattern used to close rumen incision 

• skin incision is lavaged and gowns, gloves, and drapes changed 

thoracotomy and rib resection for reticulopericarditis

• performed in the standing cow under local

• 5th or 6th rib transected and disarticlated at costochondral junction

• pericardium drained via needle and tubing

• pericardium sutured to skin

• fibrin and clots removed manually and pericardial sac lavaged

• second intention healing over 30 days

types of vagal indigestion

• type 1 = failure to eructate, ruminal tympany with free gas or frothy bloat

• type 2- omasal transport failure

• type 3- abomasal outflow failure

• type 4- indigestion associated with pregnancy

treatment of ruminal tympany 

• remove from offending det 

• reduce surface tension of bubbles using poloxalene, tide, mineral oil, DDS 

• delay turnout of hungry cattle 

• ourse roughage prior to turnout 

• oral surfactant administration daily on feed, molasses block, lipid supplement 

medical management of type I vagal indigestion

• treat the underlying cause

• if positional, roll to sternal recumbency

• orogastric or nasogastric intubation

• rumen trocharization

• calcium

• transfaunation

emergency decompression of rumen bloat

• rumen trocarization

• rumenostomy

medical management of type II and type III vagal indigestion 

• IV fluids to correct dehydration and electrolyte abnormalities 

• broad spectrum antibiotics 

• evaculation of rumen contents 

• limit access to feed and water 

• left sided exploratory lapratomy and rumentomy 

exploratory laparotomy and rumenotomy

• exploration of reticular area and liver

• removal of foreign bodies from the reticuloomasal orifice and fundus of the abomasum or identification of obstrictive mass

• abomasal impaction infused with DDS or MgSO4 and abomasal massage through rumen wall

• transfaunation

paramedian or paracostal celiotomy and abomasotomy

• abomasal exposure - access to extraluminal or intraluminal obstruction

• most effective if performed after rumenotomy and evacuation of rumen contents

• evacuation of abomasal contents by abomasotomy

• not proved to be beneficial

treatment of type 4 vagal indigestio 

• supportive therapy as described for 2 and 3

• induction of parturition 

• response to treatment is generally good once calf is delivered 

overview of treatment for abomasal displacement

• rolling

• blind tack

• omentopexy

• abomasopexy

rolling for abomasal displacement

• marginal or cull cows

• cast and rolled into dorsal recumbency

• 10-20L water administered by orogastric tube

• minimal expense, high recurrence

perform a blind tack for abomasal displacement 

• typical LDA

• clip and rough prep site, cast and roll into dorsal recumbency

• ping present on ventral midline 

• 4mm sleeved trocar passed percutaneously into the abomasum to pass gas or fluid 

• commercial toggle and suture passed through sleeve and sleeve removed 

• procedure repeated and sutures tied together to tack abomasum to body wall 

what if you are panning a bar suture for abomasal displacement and there is no ping on the ventral midline after rolling the ow?

abort the procedure

NO PING NO POKE

post op information for blind tack

• instruct ownwers to cut suture 3 weeks post operative or sooner if anorectic, abdominal distention, signs of systemic illness

• potential for tacking the wrong organ, obstruction, fistula formation

preparation for right paralumbar omentopexy 

• performed in the standing cow 

• paraventral nerve block, inverted 7, r line block 

right paralumbar omentopexy

• complete abdominal exploratory

• abomasum decompressed using needle attached to suction through abomasal wall

• abomasum returned to normal anatomic position by reaching under rumen, grasping the abomasum or omentum attachment and retracting towards the incision

• identify the pylorus and reticuloabomasal ligament

• omentopexy site 10cm caudal and dorsal to pylorus

• omentum incorporated directly into closure of body wall

• NOT FOR VERY FAT COWS

describe pyloropexy with or without omentopexy

• approach is same as omentopecy

• site is at least 5cm proximal to pylorus in pyloric antrum

• slip membranes away from seromuscular layer, 2 clamps placed 10cm apart

• abomasum incorporated into body wall closure

• anecdotal reprts of decreased recurrence

left paralumbar abomasopexy 

• allows access to greater curvature and parietal surface of abomasum when displaced to the left 

• indicated in cattle with LDA and adhesions secondary to perforated abomasal ulcers, limited adhesiolyss 

• allows correction f LDA and TRP or dystocia 

• NOT FOR RDA OR ABOMASAL VOLVULUS 

describe procedure for left paralumbar abomasopexy

• left paralumbar approach

• dilated abomasum visible slightly cranial to incision, gas not initially removed, limited abdominal exploration but provides excellent access to reticulum

• 4-6ft of non absorbable suture used to pexy abomasum to ventral abdomen

• suture passed through seromuscular layer in inchworm fashion or ford interlocking

• only seromuscular layer

• site 10cm caudal to xyphoid and 10cm lateral to idline

• procedure repeated with caudal suture 10cm caudally

• THEN decompress abomasum by pushing to the body wall while assistant draws suture throug body wall

• area between abomasum and ventral body wall explored

• assistant ties suture

complications of left paralumbar abomasopexy

• entrapment of intestine between body wall and abomasum

• penetration of seromuscular layer

• fst

advantages of right paramedian abomasopexy 

• direct access to greatest surface area of abomasum

• more secure stabolization than omentopexy or pylorpexy 

• secures fundus to ventral abdominal wall 

• proximity of abomasum to incision 

• failed omentopexy or pylopexy 

• improved cosmetic results 

disadvantages for right paramedian abomasopexy

• need for dorsal recumbency

• increased manpower

• cardiopulmonary compromise

• contraindicated with pneumonia, hypotension, distended rumen, heavily gravid uterus, MSK injury

• limited access for abdominal exploratory

sedation for right paramedian abomasopexy

• not necessary unless patient is fractious or poor facilities for restraint

• xylazine

• rumen atony

• contraindiciated in last trimester of gestation

• acepromazine

procedure for right paramedian abomasopexy 

• dordal recumbency with cow slightly tilted to the right 

• line block at proposed incision or L block 

• 15-20cm incision beginning 5cm caudal to the xyphoid and 10cm right of midline 

• abomasum should have returned to normal position 

• 2-3 mattress sutures anchors abomasum to ventra abdominal wall

• seromuscular layer incorporated into body wall closure 

indication for right paralumbar fossa exploratory and omentopexy

• right displaced abomasum or abomasal volvulus, differentiated by inability to exteriorize the pylorus and palpable twist in omentum

• counterclockwise most common

• reticulum and omasum may be in normal position or medial to abomasum

• fundus and body are dilated and covered by omentum

• pylorus located dorsal, dorsolateral, or ventrolateral to abomasum

compression of abomasal volvulus

• gas or fluid

• fluid generally associated with poor prognosis

abomasal manipulation through right PLF approach 

• rocking the distended body in a lateral → ventral → caudal direction 

• correction indicated by release of twist in omentum and exteriorization of pylous 

• followed by omentopexy or pyloropexy 

right paramedian abomasopexy

• RDA present without volvulus will allow abomasum to return to normal position

• decompress abomasum prior to repositioning

• rotate abomasum in a clockwise direction as viewed from incision

• correct position determined by palpation of reticuloabomasal ligament and visualization of the pylorus

  • standard abomasopexy performed

prognosis of abomasal displacement or volvumus

• determined by degree of tissue damage

• direct tissue damage via abomasal perforation, peritonitis, septicemia

• neuromuscular dysfunction = altered abomasal motility, dehydration, electrolyte abnormalities, poor nutrient absorption, impaction

prognosis for abomasal displacement 

• minimal vascular compromise 

• favorable long term survival 

negative prognostic indicators

• HR>100

• dehydration >6%

• hypochloremia <79

• hyponatremia, hypokalemia

• ALP >100

• mixed acid base disturbances

positive prognostic indicators

• normal hydration status

• creatinine <1.5

• ALP <100

• Chloride >95

• HR<80

treatment purpose and principles of ruminal disease 

• restore normal rumen function 

• correct underlying cause, support rumen environment, manage complications and prevent recurrence 

steps of treating rumen atony

• address the cause

• stimulate motility

• re-establish food intake

  • supportive therapy -

stimulate motility in rumen atony

• prokinetics = neostigmine or low dose erythromycin

• transfaunation 2-5 L healthy rumen fluid from a donor animal

supportive therapy for rumen atony 

• B complex vitamins 

• NSAIDs if indicated for pain or inflammation 

• oral fluids and laxatives if feed impaction 

treatment of simple indigestion

• remove spoiled food or correct feed change

• oral rumen stimulants- transfaunation is key, rumenotorics= commercial yeast, probiotics, B vitamins

• fluids = oral isotonic fluids 5-10 L

• offer moderate quality hay and restrict grain

• monitor appetite and motility, should improve within 24 hrs

generally describe bloat

• failure to eructate due to mechanical or functional disturbances

free gas bloat aka type 1 vagal indigestion 

• not a disease bit a manifestation of an underlying disease 

• sporadic 

• usually a single animal 

frothy bloat

• ruminal disease trapped as small bubbles within abnormally viscous ingesta

• related to legumes, wheat or rhye grass, high carbihydrates

• important interaction between diet, animal and microbial population

clinical signs of bloat

• asymmetrical abdominal distention

• left paralumbar fossa

• abdominal discomfort

• respiratory and cardiovascular compromise

• open mouth breathing

• death from 30 min to 4 hrs

what do you need to know when the bloat call comes in 

• how tight is the left PL fossa 

• how is she breathing 

• what is she eating 

• is she caught 

apple distension

• rumen distension, bloat

• esophageal foreign body

• carbohydrate overload

• outflow obstruction

papple distension

• esophageal obstruction

• retiiculo-omasal orifice obstruction

• abomasal outflow obstruction

• late pregnancy

pear distenson 

• late pregnancy 

• hydrops 

• urinary bladder ruptre 

• diffuse peritonitis 

tubing or trocharing a bloat cow

• tube wont go

• delfates

• partially deflates

• froth

• paloxalene administration dilute in 1 pint water, stomach tube dilute in 1 gallon

immediate relief of free gas bloat

• pass stomach tube to release gas

• if unsuccessful, trocar in left paralumbar fossa

• address cause

• rumen stimulents, calcium if hypoalcemic

• feed good quality hay, no lush legumes until resolved

treat frothy bloat 

• antifoaming agents poloxalene, mineral or vegetable oil given via stomach tude 

• severe emergency trocarization, flush with surfactant 

• prevent by gradual introduction to legumes, use anti-bloat blocks, feed dru hay before pasture turnout 

gain overload

• ruminal microbial fermentation disorder

• rapid changes in fermentable CHO available in the rumen due to interruptions in feed delivery, too rapid step up, accidental exposure, cereal grains, by products, bakery waste, fruit, high quality vegetable pastures

• simple indigestion to life threatening toxemia sand death

pathogenesis of grain overload

• D lactic acidosis = shock

• rumen fluid increases in osmolality → VFAs and lactic acid, severe dehydration, 3rd compartment like syndrome

• systemic acidosis

• other toxins liberated from rumen such as histamine and LPS

diagnosis of grain overload 

• history and risk factors 

• rumen pH 5 or lower 

• shift to gram positive flora 

• blood gas pH <7.2 

• urine pH acidic 

treatment of grain overload

• oral lavage and rinsing of rumen via kingman tube

• rumenotomi and rinsing of rumen

• rumen buffers = Mg hydroxide, enough warm water to disperse, activated charcoal, IV fluids, sodium bicarbonate containing fluids

• transfaunation

• NSAIDs, parenteral antibiotics

• B vitamins, esp thiamine

prevention of grain overload

• incremental increase over a 2-3 week period

• avoid yo yo feeding to prevent gorging

• provide adequate fiber

• use feed additive such as ionophores, sodium bicarb, or sodium bentonite to stabilize ruminal enviornment

sequelae to grain overload 

• polioencephalomalacia 

• liver abscesses 

• bactereia and emboli 

• laminitis 

• ruenitis 

• mycotic rumenitis 

acute treatment of grain overload

• if pH <5 and severe signs

• rumenotomy to remove contents

• rumen lavage and replacement

• oralantacids with magnesium hydroxide or sodium bicarb

• IV fluids

• Penicillin to reduce translocation

• thiamine to prevent polioencephalomalacia

• NSAIDs to control inflammation and endotoxemia

treatment of subacute or chronic acidosis due to grain overload

• diet modification - increase forage, add buffers

• probiotics and yeast to reestablish microflora

• monitor rumen pH and milk fat ratio in dairy cows

management of rumenitis 

• stop rumen injury, prevent systemic spread 

• remove acidotic cause 

• penicillin or oxytetracycline 

• antifungals amphotericin B or sodium iodide if mycotic 

• protect mucosa with bland diet, oral kaolin/pectin 

• supportive care fluids and B vitamins 

• adjust ration and feeding practices 

goals and management of vagal indigestion

• relieve outflow obstruction and restore motility if possible

• id and treat primary lesion - reticuloperitonitis, abscess, adhesions, abomasal impaction

• supportive care = fluids and laxatives, transfaunation, prokinetics

• prevent with magnet use and early detection of hardware disease

supportive and adjunctive therapies for rumen diseases

• transfaunation

• oral fluid therapy

• rumenotomy indications and post op care

• probiotic and yeast supplementation

• use of buffers and alkalinizing agents

• diet transition management

preventive management of rumen disorders 

• avoid rapid diet changes, maintain fiber length and DMI

• routine eval of TMR and feed quality 

• provide long stem forage 

• use of ionophores, buffers and yeast 

• monitoring tools = rumen fill scoring, milk fat:protein ratio, observation of cud chewing