Abomasal displacements and volvulus

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Abomasal Displacments and Volvulus

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Abomasal displacements and volvulus

  1. 1. Abomasal Displacments and Volvulus Dr. Satyajeet Singh
  2. 2. Greater Omentum  Consists of 2 leaves  Superficial leaf (1)  Left longitudinal groove of rumen  Greater curvature of abomasum and duodenum (2)  Deep leaf (3)  Right longitudinal groove of rumen  Decending duodenum  Both leaves form sling for intestine 1 3 2 2 2
  3. 3. Lessor Omentum (1)  Connects peritoneum between  Liver (2)  Lesser curvature of abomasum (3)  Cranial duodenum (4)  Covers right side of omasum  Key to other structures  Mesoduodenum (5)  Greater omentum (6) 2 3 4 1 5 6
  4. 4. Normal Anatomy – Left Flank
  5. 5. Normal Anatomy – Right Flank
  6. 6. Normal Anatomy - Ventral
  7. 7. Incidence of Abomasal Displacement  10% RDA  90% LDA  91% occur within first 6 weeks of calving  Most likely to occur  Adult diary cattle in early postpartum period  Prevalence in well managed herd varies  0.2 – 2.5%
  8. 8. Predisposing Factors  Abomasal atony  High grain/low roughage diets   [VFA]  Gas accumulation Distention  Roughage (large particles)  Stimulates rumination via touch receptors  Increases salivary buffer action  Hypocalcemia  Milk fever   smooth muscle tone and motility  4.8 x risk of developing LDA than normocalcemic
  9. 9. Predisposing Factors  Abomasal atony  Metritis, retained placenta, severe mastitis  Endotoxins and endogenous pyrogens (IL-1) depress motility  Result in hypocalcemia  Electrolyte disturbances  Lack of exercise/confinement  High producing diary cows  Large abdominal cavities  more room for displacement  Genetic selection
  10. 10. LDA Clinical Signs  Anorexia   fecal output   rumen motility   milk production  2o ketosis  Sunken left paralumbar fossa
  11. 11. LDA Clinical Signs  Percussion left paralumber fossa  Above/below line from point of elbow to tuber coxae  Ping over gas filled portion of abomasum
  12. 12. LDA Differential Diagnosis  Rumen tympany  Peritonitis  Pneumoperitoneum  Physometra
  13. 13. LDA Diagnosis  Clinical signs  Percussion  Liptak test  Centesis area below gas ping in “abomasum”  Fluid pH < 4.5 Abomasum  Burnt almond odor of gas Abomasum
  14. 14. Normal Transit  Simple LDA cases  normal serum electrolyte levels  Normal acid/base balance Anion Gap H2CO3 - Cl- K+ Na+
  15. 15. Normal Transit  Not a complete obstruction  Chloride secreted in abomasum  Absorbed in small intestine  + Mild hypochloremia  + Mild metabolic alkalosis
  16. 16. LDA – Right Flank
  17. 17. LDA – Left Flank
  18. 18. LDA - Ventral
  19. 19. LDA Treatment  Medical techniques  Cast in right lateral recumbency   Roll into dorsal recumbency/shake legs   Roll over to left lateralrecumbency  Stand  Surgical techniques  Right paralumbar fossa omentopexy  Left paralumbar fossa abomasopexy  Right paramedian abomasopexy  Percutaneous abomasopexy
  20. 20. LDA Prevention  Diet  Prepartum introduction of ensiled/concentrate feeds  Slowly introduce concentrates post-calving  Increase particle size of forage  Prevent hypocalcemia  Manage periparturient inflammatory diseases
  21. 21. RDA Clinical Signs and DDx  Clinical signs similar to LDA  Differential diagnosis  Cecal dilitation or volvulus  Gas in spiral colon  Small intestinal obstruction or volvulus  Torsion about root of mesentery  Pneumorectum  Pneumoperitoneum  Physometra  Abomasal volvulus
  22. 22. RDA Diagnosis  Clinical signs  Precussion  Ping under last 5 ribs in dorsal abdomen  Rectal palpation
  23. 23. Slow Transit  Potential for sequestration of HCl in abomasum  Hyochloremia (loss of anions)  Obstruction  Reabsorption of Cl- by small intestine
  24. 24. Slow Transit  Metabolic alkalosis  Compensate for loss of Cl- kidney produces H2CO3 -  Hypokalemia  Stabilize blood pH  K+ (extracellular)  H+ (intracellular)  Paradoxic aciduria  Perfusion in peripheral tissue  Aldosterone Reabsorb Na+  Secrete K+  Deplete K+ Reabsorb Na+  Secrete H+
  25. 25. RDA – Right Flank
  26. 26. RDA Treatment  Medical techniques  Rolling contraindicated  Progression to Abomasal volvulus  Surgical techniques  Difficult to distinguish RDA vs. AV  Right paralumbar fossa omentopexy or abomasopexy  Right paramedian abomasopexy
  27. 27. AV Clinical Signs  Colic  Tachycardia (> 100 bpm)  Dehydration  Bilateral abdominal distention  Feces abscent or watery but scant  AV Compete obstruction of flow of ingestia through duodenum
  28. 28. AV Differential Diagnosis  Cecal dilitation or volvulus  Gas in spiral colon  Small intestinal obstruction or volvulus  Torsion about root of mesentery  Right abomasal displacement
  29. 29. AV Diagnosis  Clinical signs  Precussion  Ping  Extends from 8th rib to middle of right paralumbar fossa  Ventral border is horizontal  Fluid in abomasum  Ballottement  Rectal palpation
  30. 30. AV Clinical Pathology  Similar to RDA but more severe  Hypochloremia  Hypohalemia  Metabolic alkalosis  Metabolic acidosis  More chronic cases  Dehydration  Poor peripheral perfusion  Shock
  31. 31. AV – Right Flank  Typical orientation  Counterclockwise viewed from right flank
  32. 32. AV - Ventral
  33. 33. AV - Cranial  Typical orientation  Clockwise viewed from cranial
  34. 34. RDA Treatment  Surgical Emergency  Preoperative  IV fluids with KCl  Hypertonic saline  Normasol  0.9% NaCl  NSAIDs  Broad spectrum antibiotics
  35. 35. RDA Treatment  Surgical techniques  Right paralumbar fossa omentopexy Best choice Integrity of abomasum often compromised Abomasopexy procedures do not work well  Progniosis  Depends on degree of damage to abomasal mucosa  Vagal indigestion syndrome common
  36. 36. Proximal Paravertebral Nerve Block  T13, L1, and L2  Sensory and motor to  Skin  Fascia  Muscle  Peritoneum
  37. 37. Proximal Paravertebral Nerve Block  Nerve most localized  Intervertebral foramen  Walk needle of caudle edge of transverse process  Single site rather than dorsal and ventral branches individually  Transverse process slopes forward  Technique  Injection site 3 – 4 cm from midline  Local bled of 2% lidocaine hydrochloride  Use 1 in 16-ga needle as trocar for 10 cm 20-ga needle
  38. 38. Proximal Paravertebral Nerve Block  Technique  Once transverse process encountered  Needle walked off caudle border and advanced 0.75 cm  10 ml 2% lidocaine hydrochloride  Temporary lateral deviation of spine  Lumbar muscle paralysis
  39. 39. Distal Paravertebral Nerve Block  Branches of T13, L1, and L2 blocked at ends of transverse processes of L1, L2, and L4 (not L3)  Technique  25 ml 2% lidocaine hydrochloride per site  18-ga needle inserted under each transverse process  10 ml 2% lidocaine hydrochloride
  40. 40. Distal Paravertebral Nerve Block  Technique  Withdrawn short distance and redirected craniad and caudad  2% lidocaine hydrochloride  Infiltration of ventral branches
  41. 41. Distal Paravertebral Nerve Block  Technique  Needle redirected dorsal and caudal to transverse process  2% lidocaine hydrochloride  Infiltration of dorsolateral branches  No deviation of spine  No lumbar muscle paralysis
  42. 42. Inverted L Nerve Block  Vertical line passes caudal to last rib  Horizontal line passes ventral to transverse processes  100 ml 2% lidocaine hydrochloride
  43. 43. Right Paralumbar Fossa Omentopexy  Vertical incision in middle of paralumbar fossa  3 – 5 cm ventral to transverse processes  20 – 25 cm long  Skin  SQ
  44. 44. Right Paralumbar Fossa Omentopexy  External abdominal oblique muscle  Internal abdominal oblique muscle  Aponeurosis of transverse abdominal muscle  Peritoneum
  45. 45. LDA Decompression  14 gauge needle attached to sterile suction hose
  46. 46. LDA Decompression  14 gauge needle attached to sterile suction hose
  47. 47. LDA Manipulation  Abomasum returned to normal position  Follow peritoneal surfaces ventrally  Hand between rumen and body wall  Elevate caudal ventral blind sac of rumen
  48. 48. LDA Manipulation  Abomasum returned to normal position  Follow peritoneal surfaces ventrally  Hand between rumen and body wall  Elevate caudal ventral blind sac of rumen
  49. 49. Right Paralumbar Fossa Omentopexy  Gently pull omentum out through incision  Retract dorsad and caudad until pylorus is visualized  Omentum on both sides of pylorus  Palpable firmness of torus pyloricus muscle  Omentopexy  Close to pyloroduodenal junction  3 – 4 cm caudal  Appendage “sows ear”  6 – 8 cm vertical section of greater omentum  Distribute pexy of wide area
  50. 50. Right Paralumbar Fossa Omentopexy  #2 or #3 chromic gut  Incorporate omentum in peritoneum and transversus abdominal muscle closure
  51. 51. Right Paralumbar Fossa Omentopexy  External/internal abdominal oblique muscles closure  Single layer, simple continuous pattern, #2 - #3 chromic gut  Skin closure  Ford interlocking pattern, #3 polymerized caprolactam (Vetafil)
  52. 52. AV Decompression  14 gauge needle attached to sterile suction hose
  53. 53. AV Manipulation  Typical orientation  Counterclockwise  Viewed from right flank  Viewed from rear
  54. 54. Advantages and Disadvantages: Right Paralumbar Fossa Omentopexy  Prognosis  LDA 86% - 90%  Complications  Redisplacement 3.6% - 4.2%  Incisional infection  Peritonitis  Advantages  Animal in standing position  Surgeon can perform procedure alone  Allows abdomial exploration  Used to correct LDA, RDA, and AV  Disadvantages  More skill  Proper position of abomasum  Proper area for fixation  Abomasum position less anatomically correct than abomasopexy  Not good if suspect adhesions beteen abomasum and left body wall
  55. 55. Left Paralumbar Fossa Abomasopexy  Identify abomasum
  56. 56. Left Paralumbar Fossa Abomasopexy  Well distented abomasum  Along greater curvature  2 – 3 cm from attachment of greater omentum  Ford interlocking pattern 5 – 7 cm  Bites through submucosa  #2 - #3 monofilament, non-absorbable  2 m long  2 long tags with straight needles  Decompress abomasum
  57. 57. Left Paralumbar Fossa Abomasopexy  Anchor suture tags  Cranial site 10 cm caudal/right of xiphoid process  Pass cranial suture through ventral abdomin  Assistant applies pressure of site with hemostats  Assistant pulls needle through skin  Repeat with caudal suture
  58. 58. Left Paralumbar Fossa Abomasopexy  Reduction of abomasum  Each suture is placed through a sponge before being tied
  59. 59. Advantages and Disadvantages: Left Paralumbar Fossa Abomasopexy  Prognosis  83.5% - 94%  Complications  Entrapment of small intestine between abomasum and body wall  Abomasal fistula formation if  Suture penetrates abomasal mucosa  Suture not removed in 2 – 3 weeks  Advantages  Animal in standing position  Best choice for cows in advanced pregnancy (> 7 months)  Best choice for rumenotomy with concurrent TRP  Disadvantages  Only for LDA not for RDA or AV  Requires assistant to guide needle placement
  60. 60. Percutaneous Abomasopexy  Toggle  5 cm long plastic rod  30 cm long nylon suture  Trocar with stylet  Used to place toggle in the abomasum
  61. 61. Percutaneous Abomasopexy  Abomasum repositioned  Position of abomasum identified
  62. 62. Percutaneous Abomasopexy  Trocar with stylet inserted into abomasum  Stylet removed  Abomasal odor confirmed  First toggle passed through cannula to abomasum
  63. 63. Percutaneous Abomasopexy  Trocar with stylet inserted into abomasum  Stylet removed  Abomasal odor confirmed  Second toggle passed through cannula to abomasum
  64. 64. Percutaneous Abomasopexy  Ends of suture tied around a sponge
  65. 65. Advantages and Disadvantages: Percutaneous Abomasopexy  Prognosis  80% - 88%  Complications  Pexy viscera or omentum  Abomasal rupture at suture site  Peritonitis  Abomasal obstruction  Advantages  Quick, inexpensive, easy to perform  May be good choice for cows that are poor surgical candidates  Disadvantages  Requires dorsal recumbency  Only for LDA not for RDA or AV  Requires assistants  Abomasum must be distended with gas
  66. 66. Laparascopic Assisted Abomasopexy  Minimally invasive technique for surgical correction of LDA  Developed to reduce incidence of complications  Traditional laparotomy  Percutaneous toggle placement
  67. 67. Laparascopic Assisted Abomasopexy  Advantages  Reduced surgical time and cost  Reduced healing time  Can immediately go back into production  Reduced milk discarding  Antibiotics not required  Allows abdominal exploratory  Any degree of gas distention  Even minimally dilated
  68. 68. Laparascopic Assisted Abomasopexy  Two-step technique  Toggle placement – standing  Suture retrieval – dorsal recumbency  One-step technique  Dorsal resumbency  One-step technique  Standing
  69. 69. Laparascopic Assisted Abomasopexy  Single toggle  Toggle bar  Stainless steel with central recess  Epoxy filling recess securing suture to toggle  Suture  Twin 80cm strands  Marker 4.5 cm from toggle bar Marker
  70. 70. Two-Step Technique: Step 1 - Standing  Left paralumbar fossa and last 3 ribs aseptically preped  2 local blebs (5 ml) 2% lidocaine  2 stab incisions (1 cm)  Laparascope portal (I)  10 cm caudal to last rib  10 cm ventral to transverse process  Instrument portal (II)  11th intercostal space  20 cm ventral to spinous process II I
  71. 71. Two-Step Technique: Step 1 - Standing  Pneumoperitoneum  Left paralumbar fossa  Position I  Veress needle with silicon tubing  Insufflation pump
  72. 72. Two-Step Technique: Step 1 - Standing  Trocar-cannula assembly inserted in left paralumbar fossa (I) through stab incision  Laparascope inserted into cannula  Abdominal exploratory
  73. 73. Two-Step Technique: Step 1 - Standing  Endoscopic picture of LDA
  74. 74. Two-Step Technique: Step 1 - Standing  Trocar-cannula assembly inserted in 11th ICS (II) through stab incision  Instrument portal
  75. 75. Two-Step Technique: Step 1 - Standing  Toggle trocar passed through instrument portal and inserted into abomasum  Toggle bar passed through trocar into abomasal lumen
  76. 76. Two-Step Technique: Step 1 - Standing  Abomasum decompressed  Excess toggle suture fully inserted into abdomen  Toggle trocar & laparascope removed  Skin incisions closed  Single interrupted suture
  77. 77. Two-Step Technique: Step 2 – Dorsal Recumbency  Right parameadian area aseptically preped  2 local blebs (5 ml) 2% lidocaine  2 stab incisions (1 cm)  Laparascope portal (III)  5 cm lateral from midline  20 cm distal to xyphoid  Instrument portal (IV)  5 cm lateral from midline  10 cm distal to xyphoid
  78. 78. Two-Step Technique: Step 2 – Dorsal Recumbency  Laparascope and grasping forceps inserted through portals
  79. 79. Two-Step Technique: Step 2 – Dorsal Recumbency  Abomasum and suture material identified  Suture retrieved using grasping forceps
  80. 80. Two-Step Technique: Step 2 – Dorsal Recumbency  Excess suture withdrawn through instrument portal up to preset marker on suture  Abomasum in proper anatomical position  Remove laparasope and cannulas  Skin incisions closed  Single interrupted suture
  81. 81. Two-Step Technique: Step 2 – Dorsal Recumbency  Suture ends each passed through separate 14 ga needles inserted through gauze stent  Needles removed  Suture tied over gauze stent  Leave 3 cm of play in suture  Suture removed after 3 – 4 weeks
  82. 82. One-Step Technique - Dorsal Recumbency  Animal is sedated and placed in dorsal recumbency  Area aseptically prepared from  Xyphoid process to 10 cm caudal to umbilicus  Width of 20 cm each side of ventral midline
  83. 83. One-Step Technique - Dorsal Recumbency  3 local blebs (5 ml) 2% lidocaine  3 stab incisions (1 cm)  Portal site I (laparoscope)  2 cm left of umbilicus  Portal site II (grasping forceps)  3 cm caudal and 7 cm right of xyphoid process  Portal site III (needle holder)  5 cm right and 3 cm cranial to umbilicus
  84. 84. One-Step Technique - Dorsal Recumbency  Fixation site IV  10 cm long line block using 2% lidocaine  3 - 5 cm right of linea alba  Centered between umbilicus and xyphoid process  Four 1-cm long skin incisions  Perpendicular to ventral midline  Spaced 2.5 cm apart
  85. 85. One-Step Technique - Dorsal Recumbency I II III IV
  86. 86. One-Step Technique - Dorsal Recumbency  Grasping forceps used to locate abomasum  Grasp abomasum in middle of greater curvature  2 – 3 cm from greater omentum attachment  Fixation site
  87. 87. One-Step Technique - Dorsal Recumbency  2 PDS suture with curved needle (1/2, 40mm) is used  Needle straightened to facilitate manipulation of needle  Needle introduced into abdomen through one of cutaneous incisions  Needle grasped intra-abdominally using needle holder
  88. 88. One-Step Technique - Dorsal Recumbency  Needle and suture passed through serous and muscular layers of abomasum  Stitch measuring 2 cm  Running perpendicular to greater curvature  Site inspected for gas or fluid leakage
  89. 89. One-Step Technique - Dorsal Recumbency  18 G needle inserted through abdominal wall  Used as guide to exteriorize needle and suture  Suture pulled out of abdominal cavity
  90. 90. One-Step Technique - Dorsal Recumbency  3 other sutures are placed in similar fashion  Correct positioning of abomasum verified by pulling gently on sutures to approximate abomasum to body wall
  91. 91. One-Step Technique - Dorsal Recumbency  Sutures are knotted  Cutaneous incisions closed
  92. 92. One-Step Technique - Dorsal Recumbency  Adhesions 3 months post-operatively
  93. 93. One-Step Technique - Dorsal Recumbency  Follows two-step technique  Except once toggle bar inserted into abomasum, suture ends not passed into abdominal cavity  Specially designed instrument is used to drive toggle suture from left flank to ventral abdomen  Suture is tied as in two-step technique
  94. 94. Right Paramedian Abomasopexy  Incision  15 – 20 cm long, parallel and 3 – 4 cm right of midline  Extending caudal from a point 4 – 8 cm caudal to xiphoid  Six distinct layers  Skin  SQ fascia  Deep pectoral muscle in cranial 1/3  External rectus sheath  Rectus abdominus muscle  Internal rectus sheath  Peritoneum
  95. 95. Right Paramedian Abomasopexy  Exploratory  Decompress abomasum and exteriorize  Identify pylorus  Omentum on both sides of pylorus  Palpable firmness of torus pyloricus muscle  Identify greater omentum  Greater curvature (arrow)  Sweeps to left side of rumen  Covering ventral surface of rumen
  96. 96. Right Paramedian Abomasopexy  Abomasopexy  3 horizontal mattress sutures  Lateral aspect of greater curvature of abomasum free of omentum  Seromuscular layer  Peritoneum and internal rectus sheath  #2 chromic gut  Simple continuous pattern  Peritoneum and internal rectus sheath  At least 6 bites incorporating abomasum  Seromuscular layer
  97. 97. Right Paramedian Abomasopexy  Closure  External rectus sheath  Horizontal mattress pattern  #3 chromic gut  Skin  Ford interlocking pattern  #3 polymerized caprolactam (Vetafil)
  98. 98. Advantages and Disadvantages: Right Paramedian Abomasopexy  Prognosis  83.5% - 95%  Complications  Incisional hemorrhage, dehiscence, herniation or fistulation  Advantages  Strong adhesions develop between abomasum and body wall  Abomasum returns near normal position during placing in dorsal recumbency  Correct LDA, RDA or AV  Disadvantages  Dorsal recumbency  Bloat, regurgitation, aspiration  Requires assistants

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