Veterinary gastrointestinal surgery


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Veterinary gastrointestinal surgery

  1. 1. • Veterinary Gastrointestinal surgery • Presented by • Dr. Rekha Pathak • Senior scientist , IVRIThe photographs have been collected from different sources i.e. Internet, text books etc
  2. 2. Gastric ulcer / Abomasal ulcer: • assoc. with chronic renal / hepatic • mast cell neoplasia • gastrin producing neoplasia • gastric neoplasia • coagulation disorder • FB / gun shot wound • ICH
  3. 3. • Uremia• Poison• Snakebite• Primary ulcers are less common• Ulcers secondary – common• Aspirin: experimentally to produce ulcers
  4. 4. • Pathophysiology:• Gastric/ duodenal mucosa/ covered with mucus layer (sulfated mucin bound to epi. cells)
  5. 5. • Offers protection – against – corrosive / digestive effects of gastric acid and pepsin (auto digestion and ulceration)
  6. 6. • Reduced mucosal bl. Flow- local ischemia – sepsis/ hemorrhagic shock – sudden expulsion of apical mucin – circumscribed popn of cells
  7. 7. • Reflux of bile salts from duodenum to stomach – bile salts – more destructive than pancreatic juices- act as detergents that solubilize lipid - cell memb and inhibit the ion transport sys.
  8. 8. • bile content – greatest – pyloric antrum – ulcer region of stomach• hyper secretion of HCL – gastrinoma ie non beta islets cell tumour of pancreas and hypergastinemia – in renal failure (gastrin is removed by kidneys)
  9. 9. – increased histamine: mastocytoma and Endotoxemia and hemorrhagic shock – NSAIDS- reduced secretion of mucus • alters the biochemical composition of mucin• ingestion of chemicals(arsenic ,cresote)• Signs: vomiting (not immediately after ingestion)• eating – gastric pain- relieved by vomiting• Hemet emesis and melena• slow bleeding: coffee colored blood• sudden - massive and semi clotted blood
  10. 10. • generalized peritonitis: gastric perforation (mostly doesn’t occur due to effective sealing with omentum)• wt. loss – hepatic/ neoplastic• additionally in calves : due to bleeding ulcers – recumbent suddenly – cold extremity- subnormal temp. tachycardia and dehydration- hypovolemic shock and death 24 hrs
  11. 11. • Abomasal ulcers : suckling calves and adult cattle (buffaloes)• adult: 1st few wks of partu.(stress and lactation)• Stress related (summer months independent of partu.)
  12. 12. • Calves: dietary transition from low DM to high DM• Trichobezoars• Asso. With impaction also
  13. 13. • Type I erosion and ulcers with slight hemorrhage• Type II bleeding ulcers• Type III perforation with acute circumscribed peritonitis• Type IV perforation with diffuse peritonitis
  14. 14. • Diagnosis:• TRP ; pain on left of xiphoid• Abomasal ulcer: pain on rt. side
  15. 15. • RG: double contrast: create pneumoperitoneum and give barium meal• Barium: ulcers appear as outpouchings from lumen containing the contrast material
  16. 16. • Fluoroscopy: helps in variable positioning and pin point the site
  17. 17. • Endoscopy: not in threatened bleeding cases (allows biopsies)• Exploratory: laparotomy if life threatening hemorrhage
  18. 18. Treatment• Surgical excision• Cranial midline incision• Carefully palpate from fundus to pylorus• If ulcers then – adhesion, serosal scarring and irregular thickened areas on gastric wall
  19. 19. • Inspect the pancreas- gastrinoma- p. nodules• If gastrinoma- en block resection of a lobe or complete pancreas(90% removal – no endocrinal insufficiency)
  20. 20. • If no ulcers found• Open stomach- find the bleeding site- also on pyloric antrum(equidistant from lesser / greater curvature)• Extend to duodenum if necessary
  21. 21. • Small ulcers : elliptical incision- mucosa closed – simple continuous – 3/0 or 4/0 absorbable chromic and interrupted Lambert on serosa and muscularis• Multiple ulcers on pyloric part – bilroth I gastrectomy technique
  22. 22. • Bilroth technique I : ligate the rt. Gastric artery near pylorus on the lesser curvature• Rt. Gastroepiploic vessels ligated• Take care not to injure the pancreas• Pyloric and gastric branches supplying the area to be resected are ligated
  23. 23. • 2 st. intestinal clamps are placed across the pyloric antrum• another 2 are placed distal to the pylorus and avoid the common bile duct.• Excise the pyloric sphincter and canal
  24. 24. • Gastric mucosa is apposed with 3-0 synthetic absorbable suture in an Cushing pattern starting from the lesser curvature and continuing towards the greater curvature
  25. 25. • Equal in size to the duodenal dia• Apposed – 3-0 – synthetic absorbable, polypropylene, or nylon – lamberts pattern• Duodenum is then anastamosed with stomach
  26. 26. Gastric acute dilatation and torsion• Gastric dilatation- volvulus (GDV)• Only dilation common in puppies• Overeating/ parasitism• Larger and giant breeds – deep chested
  27. 27. • Overeating – relieved by induced vomiting or passing stomach tube• Parasitism• Pica• Postprandial activity• Delayed gastric emptying- pyloromyotomy
  28. 28. • Pathophysiology• Rotation after dilation• Aerophagia – source of intragastric gas• Distended stomach (gas + fluid) – more prone to rotation• Prevents eructation – esophagus and emptying from duodenum• Distension increases
  29. 29. • Presses the caudal vena/ portal vein – reduced venous return – red. CO. – red. Tissue perfusion and shock• Ischemic bowel – release toxins- endotoxemia-shock and hypotension• Red. Ventilation- pressure on diaphragm
  30. 30. • Acid base and electrolyte disturbance• Myocardial ischemia• Rotation of stomach – strangulation of gastric vessels- edema and anoxia –gastric wall ulceration and necrosis
  31. 31. • Clinical signs• Acute onset of cranial abd. Distention• Vomiting• Profuse salivation-pain• Prolonged CRT, Pallor, weak pulse• Shock (pooling of blood in spleen due to rotation of splenic vessels, hypovolemia and hypotension)• Dyspnea
  32. 32. • RG signs: differentiate simple gastric distension from GDV• Gas filled stomach- 50-75% - splenic position is normal if no volvulus• In GDV –pylorus is located cranial/dorsal – fundus• Position of spleen may not be normal
  33. 33. • A tissue density line dividing the gas filled stomach into compartments• VD - pylorus is near or near to the left of the midline• Gastric perforation- pneumoperitoneum• Clockwise 270• Anticlockwise 90
  34. 34. • Preoperative care• Gastric decompression• Needle trocarization 18 G needle• Thrust on rt. Or left wall – point of greatest distension
  35. 35. • 2-3 needles – relieves gas component of distension• Alternatively – if not effectively reduced – stomach• Pass the through mouth gag- resistance is encountered in gastro esophageal junction – rotate and advance
  36. 36. • Removal of intragastric gas – trocarization- corrects the gastro esophageal angle-allows passage of S. tube• Passage of st doesn’t mean absence of g. rotation• Withdraw the tube after decompression
  37. 37. • Sometimes for decompression – temporary Gastrotomy is constructed• Close the Gastrotomy wound and proceed for surgical correction of rotation (Decompression doesn’t always result in normal gastric position)• Shock therapy
  38. 38. • Surgical correction of volvulus• If surgery is delayed – gastric necrosis worsens• Reposition the stomach by derotating it• Avoid injury to splenic v. (digital palpation of esophagus reveals the direction of rotation• Pylorus is a good / useful landmark – firm consistency)• See the viability of gastric tissue – necrosed and non-viable – esp. the greater curvature is damaged
  39. 39. • Serosal color, thickness of wall and vascular patency• Partial gastrectomy• Hemoperitoneum - centesis of abdominal cavity- splenic torsion and gastric torsion• Blue-black areas/diffuse petechial /ecchymotic stomach- gastrectomy not indicated – becomes normal after decompression
  40. 40. • Spleenectomy – damaged• Gastropexy- red. Rate of GDV• Pyloric antral region is fixed to the adjacent rt. abdominal wall• Gastropexy is always performed on the rt. Side of the stomach – some rotation – still occur- bet.left gastric wall and left abd.wall
  41. 41. G. neoplasm• Avg. age 8 y• Alimentary tract: oral cavity – rarely in stomach• Persistent vomiting unrelated to eating
  42. 42. • Within the antrum on the lesser curvature• Metastasis: liver, lungs, spleen• Leiomyoma/ rhabdomyosarcoma/ polyps (solitary or multiple)
  43. 43. • Polyps – due to sharp fragment of bones- resting for long in antrum - injure mucosa – herniation of sub mucosa• Clinical signs; anorexia
  44. 44. • Loss of wt. Obstructing gastric out flow• Normal peristalsis is interfered• Anemia• Abd. Pain
  45. 45. • Emesis unrelated to ingestion of food /water• Melena• palpation• Exploratory laparotomy
  46. 46. • RG: contrast – filling defect
  47. 47. • Endoscope• Ultrasonography• Adenocarcinoma: most common• Sex predilection for males• Treatment• Chemotherapy: not successful
  48. 48. • Surgical• Gastrectomy: Partial gastrectomy is done• Removal of any portion of the stomach and up to (30-40%) in antrectomy• Partial gastrectomy – 40-70%• Subtotal gastrectomy : 70- 90%• Antrectomy: reconstruction- gastroduodenostomy (bilroth I ) or gastrojejunostomy(II)
  49. 49. • Two variations of partial gastrectomy• A-C : stay sutures are placed to elevate the stomach and to minimize leakage• Necrotic tissue is excised with a rim of viable tissue• A two layer inverting closure is used• D-I : atraumatic forceps are placed across viable tissue and necrotic tissue is excised
  50. 50. • The stomach body is subsequently closed with a parker- Kerr line• The first inverting layer suture is placed over the clamps• Remove clamps, pull and invert the suture line• Second inverting suture row
  51. 51. • End to end anastomosis of stomach
  52. 52. • Bilroth II – performed if more radical gastrectomy is required, if there is excessive duodenal involvement or both
  53. 53. Bloat• Bloat : Major problems- GIT – cattle and buffaloes• Higher in buffaloes• Acute/chronic• Gaseous bloat – free gas - dorsal part of rumen• Frothy bloat – gas trapped with ingesta- dispersed throughout the rumen content
  54. 54. • Acute: rapid feeding and sudden diet change – large ruminants• s. ruminants – large quantities of grain ingestion/cereals• More pressure on diaphragm – hypoventilation and red. Venous return to the heart
  55. 55. • signs: bulge on Para lumbar fossa• Abdominal distension• Cyanotic mm• v. serious – lying down – asphyxiated – open mouth- protruded tongue and tachycardia
  56. 56. • Treatment: puncture wall – left side with trocar and canula• if frothy – antifoaming agents – turpentine oil (80ml) + mustard oil (500-1000 ml)• antifroth prepn. – bloatosil• gives immediate relief to ailing animal• avoid conc. – 2-3 days and leguminous fodder
  57. 57. • Resort to rumenotomy / rumenostomy• S. animal: IV- RL or oral soda bicarb• Chronic bloat: TRP (FBS) – reticuloperitonitis/ fibrinous pneumonia – pleuritis involving the vagus nerve• Liver abscess, splenic cyst and abscess, enlarged mediastinal lymph nodes, pyloric stenosis• Rumen fistulation / rumenotomy can be done
  58. 58. • Rumen fistulation:• Anesthesia and surgical prepn.: standing position• Sternal recumb. – Camel• Left Para lumbar fossa• Circular area – ventral to transverse process of lumbar vertebrae- approx 10 cm dia.- infiltrated
  59. 59. • A circular piece of skin (4cm) – removed to expose the underlying abdominal mus.• Bluntly dissect and expose rumen – grasp – pulled in a cone fashion to the skin surface
  60. 60. • Anchor with 4 horizontal mattress suture through rumen and skin
  61. 61. • Remove central portion of rumen• Incised edge of rumen is sutured to the skin with simple interrupted and non- absorbable• Alternately – all the layers – apply interrupted mattress sutures in circular rim
  62. 62. • Rumenotomy:• Indications: FB, ruminal impaction, bloat, atony of omasum or abomasum• Inverted L – block• Local infiltration along line of incision
  63. 63. • Para vertebral block• Surgical technique: 20 cm incision- middle of tuber coxae and last rib 5 cm ventral to lumbar process
  64. 64. • Caudal to last rib (close to reticulum)• Esp. in deep bodied animals
  65. 65. • Anchor rumen to the incision to avoid contamination of abdominal m. and peritoneum
  66. 66. • Continuous inverting pattern – non- absorbable
  67. 67. • Alternatively use weingarts ring (quicker)• Incise rumen with scalpel
  68. 68. • Evacuate and explore for FB in reticulum and remove• Try to feel for abscess in reticular area• Reticulum is swept with a magnet to retrieve the iron FB• Rumen cud + soda bicarb= mineral oil
  69. 69. • Scrub and discard the soiled instruments• Close with double row of lamberts or inversion sutures• Antibiotic and fluid therapy