Basic of Small Animals Stomach Surgery
Grossly, the stomach is divided into the cardia, fundus, body, and pyloric portions. The point where the intraabdominal esophagus blends into the stomach on the left side is termed the cardia. The cardiac notch is formed between the cardia and the blind outpouching of the stomach, termed the fundus. On the medial aspect the esophagus joins the lesser curvature of the stomach without a distinct anatomic landmark of the junction. The incisura angularis (angular notch) produces an intraluminal protrusion of tissue at approximately the midpoint of the lesser curvature that separates the antrum and the body. This angular notch is the area in which the papillary process of the liver lies......
By DR.Kambiz Yousefi
Kambiz.u3fi@me.com
science has an evolving nature. what happened today may not be tomorrow, what is not today may happen tomorrow.
No one is complete so reading and thinking may open the door to the hidden ground.
science has an evolving nature. what happened today may not be tomorrow, what is not today may happen tomorrow.
No one is complete so reading and thinking may open the door to the hidden ground.
Abstract
This case report describes the diagnosis and management of a large mesenteric cyst in a 55 year old lady who presented with abdominal distension & with mass in the left upper quadrant. Mesenteric cysts are rare, benign, abdominal tumors to which <1000 cases have been reported in the literature. While 40% of cases are incidental findings found either through physical examination or imaging, they can cause non-specific abdominal symptoms including pain, altered bowel habits, nausea/vomiting or anorexia. Less commonly, 10% of cases can present with bowel obstruction, volvulus, torsion or shock. In general, the lack of characteristic clinical and radiological features presents as a diagnostic difficulty.
The mainstay in imaging is computerized tomography (CT). CT identifies and helps aid the decision to pursue a laparoscopic or open laparotomy approach, where complete surgical resection is the ultimate goal. In our patient a CT Abdomen & Pelvis showed a large, loculated cystic mass measuring 30cm in cranio-caudal length and 16cm in the transverse and anterior/posterior diameter. While different approaches have been described in the literature to surgically resect such cysts, our approach was largely reflective of size and adherence to surrounding structures in this case. A laparotomy was performed using an upper mid-line 7 cm incision; 4500cc of fluid was aspirated from the cyst which was found to originate from the small bowel mesentery. A complete resection of the multi-loculated cystic sac was done that included the resection of the middle mesenteric vein. The post-operative period was uneventful. The patient was discharged on post-operative day 2. The Histopathology identified the mass as a multi-loculated peritoneal inclusion-type cyst.
mesenteric cyst is fluid collection between two layers of small bowel mesentery, Mesenteric cysts can be simple or multiple, unilocular or multilocular, and they may contain hemorrhagic, serous, chylous, or infected fluid.
The fluid is serous in ileal and colonic cysts and is chylous in jejunal cysts.
They can range in size from a few millimeters to 40 cm in diameter.
1. Obstructive ileus is a condition characterized by a blockage in the intestines. 2. Ileus obstructive refers to a situation where there is a hindrance in the normal flow of the intestines. 3. The term obstructive ileus is used to describe a condition where there is an obstruction in the intestines, causing a disruption in the normal movement of food and fluids. Ileus refers to the intolerance of oral intake due to inhibition of the gastrointestinal propulsion without signs of mechanical obstruction. The diagnosis is often associated with surgery, medications, trauma, peritonitis, or severe illness. Mechanical obstruction has to be ruled out, and the diagnosis of ileus is dependent on radiographic evidence, usually on a CT scan or small bowel series. This activity reviews the evaluation and management of an Ileus and highlights the role of the interprofessional team in improving care for patients with this condition.
Objectives:
Identify the etiology of ileus.
Outline the typical presentation of a patient with ileus.
Review the management options available for ileus.
Identify interprofessional team strategies for improving care coordination and outcomes in patients with ileus.
Access free multiple choice questions on this topic.
Go to:
Introduction
Ileus, also known as paralytic ileus or functional ileus, occurs when there is a non-mechanical decrease or stoppage of the flow of intestinal contents.[1][2] Bowel obstruction is a mechanical blockage of intestinal contents by a mass, adhesion, hernia, or some other physical blockage. These two diseases may present similarly, but treatment can be very different depending on the underlying pathology.
Ileus is an often unavoidable consequence of abdominal or retroperitoneal surgery, but can also be found in severely ill patients with septic shock or mechanical ventilation. Due to the delayed refeeding syndrome seen after an ileus, postoperative ileus has a large economic impact in the United States alone.[3] An ileus usually manifests itself from the third to the fifth day after surgery and usually lasts 2 to 3 days with the small bowel being the quickest to return to function (0 to 24 hours), followed by the stomach (24 to 48 hours), and lastly the colon (48 to 72 hours).[2][4][5] A prolonged ileus is diagnosed if the ileus exceeds 2 to 3 days with the continued absence of obstruction signs.[6]
Go to:
Etiology
The cause of ileus has yet to be clearly defined. There are, however, several risk factors that have been shown to increase the likelihood and endurance of an ileus.[7]
Prolonged abdominal/pelvic surgery
Lower gastrointestinal (GI) surgery
Open surgery
Retroperitoneal spinal surgery
Opioid use
Intra-abdominal inflammation (sepsis/peritonitis)
Peritoneal carcinomatosis
Perioperative complications (pneumonia, abscess)
Bleeding (intraoperative or postoperative)
Hypokalemia
Delayed enteral nutrition or nasogastric (NG) tube placement
The risk for an ileus is influenced by a variety of fx
Abstract
This case report describes the diagnosis and management of a large mesenteric cyst in a 55 year old lady who presented with abdominal distension & with mass in the left upper quadrant. Mesenteric cysts are rare, benign, abdominal tumors to which <1000 cases have been reported in the literature. While 40% of cases are incidental findings found either through physical examination or imaging, they can cause non-specific abdominal symptoms including pain, altered bowel habits, nausea/vomiting or anorexia. Less commonly, 10% of cases can present with bowel obstruction, volvulus, torsion or shock. In general, the lack of characteristic clinical and radiological features presents as a diagnostic difficulty.
The mainstay in imaging is computerized tomography (CT). CT identifies and helps aid the decision to pursue a laparoscopic or open laparotomy approach, where complete surgical resection is the ultimate goal. In our patient a CT Abdomen & Pelvis showed a large, loculated cystic mass measuring 30cm in cranio-caudal length and 16cm in the transverse and anterior/posterior diameter. While different approaches have been described in the literature to surgically resect such cysts, our approach was largely reflective of size and adherence to surrounding structures in this case. A laparotomy was performed using an upper mid-line 7 cm incision; 4500cc of fluid was aspirated from the cyst which was found to originate from the small bowel mesentery. A complete resection of the multi-loculated cystic sac was done that included the resection of the middle mesenteric vein. The post-operative period was uneventful. The patient was discharged on post-operative day 2. The Histopathology identified the mass as a multi-loculated peritoneal inclusion-type cyst.
mesenteric cyst is fluid collection between two layers of small bowel mesentery, Mesenteric cysts can be simple or multiple, unilocular or multilocular, and they may contain hemorrhagic, serous, chylous, or infected fluid.
The fluid is serous in ileal and colonic cysts and is chylous in jejunal cysts.
They can range in size from a few millimeters to 40 cm in diameter.
1. Obstructive ileus is a condition characterized by a blockage in the intestines. 2. Ileus obstructive refers to a situation where there is a hindrance in the normal flow of the intestines. 3. The term obstructive ileus is used to describe a condition where there is an obstruction in the intestines, causing a disruption in the normal movement of food and fluids. Ileus refers to the intolerance of oral intake due to inhibition of the gastrointestinal propulsion without signs of mechanical obstruction. The diagnosis is often associated with surgery, medications, trauma, peritonitis, or severe illness. Mechanical obstruction has to be ruled out, and the diagnosis of ileus is dependent on radiographic evidence, usually on a CT scan or small bowel series. This activity reviews the evaluation and management of an Ileus and highlights the role of the interprofessional team in improving care for patients with this condition.
Objectives:
Identify the etiology of ileus.
Outline the typical presentation of a patient with ileus.
Review the management options available for ileus.
Identify interprofessional team strategies for improving care coordination and outcomes in patients with ileus.
Access free multiple choice questions on this topic.
Go to:
Introduction
Ileus, also known as paralytic ileus or functional ileus, occurs when there is a non-mechanical decrease or stoppage of the flow of intestinal contents.[1][2] Bowel obstruction is a mechanical blockage of intestinal contents by a mass, adhesion, hernia, or some other physical blockage. These two diseases may present similarly, but treatment can be very different depending on the underlying pathology.
Ileus is an often unavoidable consequence of abdominal or retroperitoneal surgery, but can also be found in severely ill patients with septic shock or mechanical ventilation. Due to the delayed refeeding syndrome seen after an ileus, postoperative ileus has a large economic impact in the United States alone.[3] An ileus usually manifests itself from the third to the fifth day after surgery and usually lasts 2 to 3 days with the small bowel being the quickest to return to function (0 to 24 hours), followed by the stomach (24 to 48 hours), and lastly the colon (48 to 72 hours).[2][4][5] A prolonged ileus is diagnosed if the ileus exceeds 2 to 3 days with the continued absence of obstruction signs.[6]
Go to:
Etiology
The cause of ileus has yet to be clearly defined. There are, however, several risk factors that have been shown to increase the likelihood and endurance of an ileus.[7]
Prolonged abdominal/pelvic surgery
Lower gastrointestinal (GI) surgery
Open surgery
Retroperitoneal spinal surgery
Opioid use
Intra-abdominal inflammation (sepsis/peritonitis)
Peritoneal carcinomatosis
Perioperative complications (pneumonia, abscess)
Bleeding (intraoperative or postoperative)
Hypokalemia
Delayed enteral nutrition or nasogastric (NG) tube placement
The risk for an ileus is influenced by a variety of fx
Intestinal obstruction is the mechanical impairment which is partial or complete blockage of the bowel that results in the failure of the passage of intestinal content through the intestine.
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
---------- Forwarded message ----------
From: UCD Graduate '09 None <ucdgrad09@gmail.com>
Date: 2009/2/12
Subject: Bambury tutorial Upper GI Surgery
To: ucdgrad09@gmail.com
She does not know that we have this so please don't print it and bring it to
the lecture
Annular pancreas is an uncommon condition in adults.
The ring formation generally originates from the failure of
normal clockwise rotation of ventral pancreas. First
described by Tiedmann in 1818, its incidence is
1:20,000 population. It has bimodal presentation i.e is seen
either in Infants or in 4th & 5th decade of life.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
2. A N A T O M Y
Grossly, The Stomach Is Divided Into The Cardia, Fundus, Body, And Pyloric Portions
3. A N A T O M Y
The Point Where The Intraabdominal Esophagus Blends Into The Stomach On The Left Side Is Termed
The Cardia.
The Cardiac Notch Is Formed Between The Cardia And The Blind Outpouching Of The Stomach, Termed The
Fundus.
The Incisura Angularis (Angular Notch) Produces An Intraluminal Protrusion Of Tissue At Approximately The
Midpoint Of The Lesser Curvature That Separates The Antrum And The Body. This Angular Notch Is The Area In
Which The Papillary Process Of The Liver Lies.
During Endoscopic Examination Of The Stomach, The Incisura Angularis Is An Important Landmark.
The Pyloric Portion Of The Stomach Is Divided Into The Thinner Walled Pyloric Antrum And The Area Known As
The Pyloric Sphincter, Which Is Defined By The Double Muscle Layer That Surrounds It.
4. A N A T O M Y
Omentum
The Greater And Lesser Omentum Are Attached To The Stomach At The Greater And Lesser Curvatures, Respectively.
The Greater Omentum Is Divided Into Three Portions Known As The Bursal, Splenic, And Veil Portions
The Bursal Portion Attaches Along The Greater Curvature Except On The Left, Where It Runs Obliquely Across The
Dorsal Surface Of The Stomach And Joins The Lesser Omentum To Close The Omental Bursa.
The Splenic Portion Of The Greater Omentum Forms The Gastrosplenic Ligament, Through Which The Gastroepiploic
Vessels Course To The Stomach.
A Portion Of The Lesser Omentum Forms The Hepatogastric Ligament That Passes From The Liver To The Stomach.
7. A N A T O M Y
Gastric Layers
The Stomach Wall Is Composed Of Four Distinct Layers; From The External To The Internal Surface,
They Are The Serosa, Muscle, Submucosa, And Mucosa. The Muscular Composition Of The Stomach Is
Divided Into Three Layers.
1- The Longitudinal Fibers On The Greater Curvature Of The Stomach Pass Longitudinally From The Esophagus
To The Duodenum
2- The Inner Circular Layer Begins At The Cardia
3- The Oblique Muscle Fibers
8. P R E S U R G I C A L P R E P A R A T I O N
Fa st ing
A nest het ic C o nsidera tions
A nt imicro bials
Withholding Food For A Minimum Of 8 To 12 Hours Before Surgery Has Been Recommended To Ensure An Empty Stomach And Minimize The Risk
For Gastric Spillage During The Operative Procedure
In Cases Of Functional Pyloric Outflow Obstructions, The Duration Of The Required Fast May Be Significantly Longer To Ensure An Empty Stomach.
Anesthetic Considerations For Patients Undergoing Gastric Surgery Are Closely Tied To The Underlying Disease Process. Clinical
Signs Frequently Associated With Gastric Disorders Include Vomiting And Regurgitation; As Such, Administration Of
Anticholinergics Such As Atropine Or Glycopyrrolate Should Be Considered In An Effort To Reduce Gastric Secretions
Bacterial Numbers In The Stomach Are Significantly Less Than In The Remainder Of The Gastrointestinal Tract Because Of The Acidic Nature Of
Stomach Secretions. In Specific Cases Such As Gastric Perforation, Obstructive Disease With Possible Bacterial Overgrowth, And Gastric Dilatation
Volvulus, Antibiotics Are Indicated Perioperatively. In Other Instances When The Lumen Of The Stomach Must Be Entered And The Surgeon Believes
There Is An Increased Risk For Contamination, Administration Of Prophylactic Antibiotics Should Be Considered.
9. G E N E R A L S U R G I C A L P R I N C I P L E S
Several Factors Make Gastric Surgery Challenging. First And Foremost, The Risk For Gastric Content Leakage Is
Considerable And, If Not Addressed, May Result In Significant Postoperative Morbidity And Mortality.
A p p ro a ch
Gastric Surgery Of The Small-animal Patient Is Most Commonly Performed Through A Ventral Midline
Abdominal Incision That Extends From The Xiphoid Process Of The Sternum To A Point Well Caudal Of The
Umbilicus And, In Many Instances, Extending To The Pubis
In Rare Instances When Exposure Of Only A Portion Of The Stomach Is Required, A Paracostal Approach May
Be Used. This Is Achieved By Making A Curved Incision Approximately 2 Cm Caudal To The Last Rib
La v a g e
The Abdominal Cavity Should Be Lavaged With Sterile Saline Or Lactated Ringer’s Solution And Suctioned
Dry After The Gastrointestinal Tract Is Closed. Temperature Recommendations For Lavage Solution Vary, With
37°C To 39°C (98.6°F To 102.2°F) Most Commonly Reported.
10. Ga st ric C lo sure
The Closure Technique Used For Gastric Surgery Depends On The Incision Location And Indication For The Initial
Incision Or Resection. Routine Closure Of A Gastric Body Incision May Be Achieved With A Continuous Double-layer
Inverting Closure In Which The First Suture Line Is Full Thickness And The Second Line Incorporates Only The Serosa
And Muscular Layers. Alternatively, The First Suture Line May Appose Only The Mucosa And The Adherent Layer Of
Submucosa, And The Second Line Inverts The Remaining Layers Of Gastric Tissue. Inverting Patterns Used For These
Applications Include Cushing, Connell, And Lembert Patterns. A Two-layer Closure Technique Is Advantageous Because
The Inner Layer Provides Hemostasis Of Gastric Mucosa And Submucosa And The Outer Layer Provides An Additional
Seal Against Gastric Content Leakage.
Sut ure M a t eria l
The Choice Of Appropriate Suture Material For Closure Of The Stomach Is Dictated By The Need For A Material That
Resists Rapid Degradation In The Acid- And Enzymerich Environment Of The Gastric Lumen For The 14 Days Necessary
To Regain Gastric Wall Strength. Most Commonly, Monofilament Absorbable Materials Such As Polydioxanone,
Polyglyconate, Or Poliglecaprone 25 Are Used.
G E N E R A L S U R G I C A L P R I N C I P L E S
11. Ga st ric Bio psy
Gastric Biopsy Is Indicated In The Presence Of Gross Disease Of The Stomach And When Clinical Signs Are
Consistent With Upper Gastrointestinal Disease. Endoscopic Gastric Biopsy Is Associated With A Low Morbidity
And A Low Risk For Complications. However, In Instances When The Disease Is Submucosal Or Scirrhous In
Nature, Endoscopic Biopsy Is Inadequate Because Of The Inability To Obtain A Full-thickness Gastric Wall Sample.
A Simple Stab Incision May Be Made Into The Lumen Of The Stomach While Providing Upward Retraction With
Appropriate Thumb Forceps. The Incision Is Then Extended With Metzenbaum Scissors, And One Edge Of The
Incision Is Removed To Provide A Full-thickness Tissue Sample. Closure Of The Biopsy Site Is Most Commonly
Achieved With A Two-layer Pattern.
G E N E R A L S U R G I C A L TECHNIQUES
12. Ga st ro tomy
The Stomach Is Isolated From The Remainder Of The Abdomen With Moistened Laparotomy Sponges, And
Stay Sutures Are Placed At The Appropriate Points. A Gastrotomy Is Performed On The Ventral Surface Of
The Stomach Midway Between Its Lesser And Greater Curvatures In The Area With The Least Vascularity.
The Underlying Reason For The Gastrotomy Dictates The Location And Length Of The. Closure Of The
Gastrotomy Incision Is Accomplished In The Same Fashion As Described For Closure Of A Gastric Biopsy.
Pa rt ia l Ga st rect omy
• Partial Gastrectomy Is Most Frequently Performed To Remove Necrotic Stomach Wall Associated With Gastric
Dilatation Volvulus Or To Resect A Neoplasm.
• Blood Supply To The Spleen Should Be Evaluated To Determine Whether It Should Be Removed Concurrently.
• Depending On The Shape Of The Resulting Defect, The Closure May Occur Perpendicular Or Parallel To The Long
Axis Of The Stomach.
• Omentum Can Be Tacked Over The Site To Provide Additional Blood Supply And Seal The Area.
G E N E R A L S U R G I C A L TECHNIQUES
13. D e t e r m i n i n g Ti s s u e Vi a b i l i t y
Pa rt ia l Ga st rect omy
When Performing Partial Gastrectomy, It Is Critical That All Nonviable Tissue Be Excised.
Viability Of Gastric Mucosa Does Not Predict Overall Health Of The Gastric Wall; Thus
Other Criteria Must Be Used To Assess Gastric Wall Viability. Subjective Criteria Include
Gastric Wall Thickness, As Measured By Palpation; Serosal Surface Color; Evidence Of
Serosal Capillary Perfusion; And Presence Of Peristalsis.
G E N E R A L S U R G I C A L TECHNIQUES
14. Ga st ric Wa ll R esect io n A nd C lo sure
The Closure Technique Used For Partial Gastrectomy Depends On The Anatomic Location Of The Portion To
Be Resected And The Remaining Lumen Diameter. When The Lumen Diameter Permits And The Presence Of
Inverted Tissue Does Not Increase The Potential For Pyloric Outflow Obstruction, A Two-layer Inverting
Pattern Is Appropriate. When The Lumen Diameter Is Not Adequate To Allow Inverting Closure, A Simple
Continuous Suture Pattern Is Most Appropriate.
G E N E R A L S U R G I C A L TECHNIQUES
15. Ga st ric Wa ll Inv a g ination
• Invagination Has Been Proposed As An Alternative To Partial Gastrectomy In Cases With Areas Of Questionable
Viability.
• A Simple Continuous Or Inverting Suture Pattern And A Second Inverting Suture Pattern, With Bites Placed In
Healthy Tissue On Each Side Of The Necrotic Portion Of The Stomach, Are Placed To Invaginate The Unhealthy
Gastric Wall.
• The Result Is Apposition Of Healthy Tissue Over Necrotic Tissue Without Penetration Into Gastric Lumen, Thereby
Decreasing The Risk For Gastric Contents Spillage. The Devitalized Area Of Stomach Wall Is Then Sloughed Into
The Gastric Lumen And Digested.
G E N E R A L S U R G I C A L TECHNIQUES
16. Ga st ro pex y
Gastropexy Is The Creation Of A Permanent Adhesion Of The Stomach To The Adjacent Body Wall.
Gastropexy Is Most Commonly Performed For Prevention Of Gastric Dilatation Volvulus But Is Also
Used In The Treatment Of Hiatal Hernia.
• Gastropexy For Prevention Of Gastric Dilatation Volvulus Is Performed Between The Pyloric
Antrum And The Right Abdominal Wall.
• A Variety Of Gastropexy Techniques Have Been Reported With Varying Degrees Of Success.
Techniques Include Incisional, Beltloop, Circumcostal, Endoscopically Assisted, And Laparoscopic
Gastropexy.
G E N E R A L S U R G I C A L TECHNIQUES
17. The Results Of Biomechanical Testing For Commonly Used Open Gastropexy Techniques Are Similar
Quantitative Results Of Biomechanical Testing Must Be Interpreted Carefully Because The Absolute Strength Of
Gastropexy Required To Prevent Development Of Gastric Dilatation Volvulus Is Unknown. There Has Not Been
An Experimental Study Of Strength Of Incorporating Gastropexy.
G E N E R A L S U R G I C A L TECHNIQUES
18. Incisio na l Ga st ro pexy
Incisional Gastropexy For Prevention Of Gastric Dilatation Volvulus Is Performed By Creating A 4- To 5-cm
Seromuscular Incision In The Gastric Antrum Either Parallel Or Perpendicular To The Long Axis Of The
Stomach.
Care Should Be Taken To Avoid Penetration Of The Gastric Mucosa.
A Second Incision Is Made Through The Peritoneum And The Transversus Abdominis Muscle On The
Lateral Or Ventrolateral Right Abdominal Wall Approximately 2 To 3 Cm Caudal To The Last Rib.
Gastric And Abdominal Wall Incisions Are Apposed Using 2-0 Monofilament Absorbable Suture In A
Simple Continuous Suture Pattern, Beginning With The Craniodorsal Edges Of The Incision
G E N E R A L S U R G I C A L TECHNIQUES
19. Incisio na l Ga st ro pexy
The Technique For Incisional Gastropexy For Treatment Of Hiatal Hernia Is Similar
In All Respects Except That It Is Performed On The Left Side Of The Abdomen.
Incisions Are Made Through The Seromuscular Layer Of The Fundus And
Correspondingly Through The Peritoneum And Transversus Abdominis Muscle On The
Left Side Of The Abdominal Wall Caudal To The Last Rib.
G E N E R A L S U R G I C A L TECHNIQUES
20. Incisio na l Ga st ro pexy
The Body Wall Is Retracted After The Balfour
Retractor Is Removed To Facilitate Visualization.
G E N E R A L S U R G I C A L TECHNIQUES
21. Incisio na l Ga st ro pexy
After Determining The Appropriate Position Based On The Normal Anatomic
Location Of The Stomach, An Incision Is Made Through The Transversus
Abdominis Muscle Caudal To The Last Rib. A Second Incision Is Made Through
The Serosa And Muscular Layers Of The Stomach On The Ventral Surface Of The
Pyloric Antrum. The Mucosa Will Bulge From The Incision.
G E N E R A L S U R G I C A L TECHNIQUES
22. Incisio na l Ga st ro pexy
The Incisions In The Body Wall And Stomach Are Apposed Using Two
Continuous Suture Lines With The Most Dorsal Incision Closed First To
Facilitate Visualization.
G E N E R A L S U R G I C A L TECHNIQUES
23. Incisio na l Ga st ro pexy
Completion Of The Second Suture Line.
G E N E R A L S U R G I C A L TECHNIQUES
24. Belt - Lo o p Ga st ro pex y
Belt-loop Gastropexy Is A Variation On Incisional Gastropexy. With The Belt-loop Technique A
Seromuscular Flap Is Elevated From The Pyloric Antrum And Passed Through A Tunnel Created
Between Two Parallel Incisions In The Abdominal Wall.
The Seromuscular Gastric Flap Is Based Along The Greater Curvature Of The Stomach And Incorporates
Branches Of The Gastroepiploic Artery In Its Origin.
The Flap Is Created By Making Two Parallel Incisions Approximately 4 Cm Long And 3 Cm Apart And
Connecting These Incisions At Their Most Cranial Aspect.
G E N E R A L S U R G I C A L TECHNIQUES
25. Belt - Lo o p Ga st ro pex y
The Resultant Seromuscular Flap Is Undermined From The Mucosal Layer Below. Next, Two 5-cm-
long Abdominal Wall Incisions That Penetrate The Peritoneum And Transversus Abdominis Muscle Are
Made Approximately 3 Cm Apart.
Muscle Between The Two Incisions Is Undermined, Creating A Tunnel Through Which The
Seromuscular Gastric Flap Is Passed.
G E N E R A L S U R G I C A L TECHNIQUES
26. The Gastric Flap Is Passed Through The Tunnel By First Bringing The Stomach Close To The Body Wall
To Decrease Tension Applied To The Flap As It Is Passed And Then Using A Stay Suture Placed In The
Free End Of The Flap To Direct The Flap Through The Tunnel.
The Flap Is Sutured Back To The Site From Which It Was Elevated Using A Simple Interrupted Or
Continuous Pattern Of 2-0 Or 3-0 Absorbable Monofilament.
Belt - Lo o p Ga st ro pex y
G E N E R A L S U R G I C A L TECHNIQUES
27. Belt - Lo o p Ga st ro pex y
A Seromuscular Flap Is Raised, Originating From The Pyloric Antrum And
Incorporating A Blood Supply In The Base Of The Flap.
G E N E R A L S U R G I C A L TECHNIQUES
28. Belt - Lo o p Ga st ro pex y
Parallel Transverse Incisions Are Made In The Transversus
Abdominis Muscle.
G E N E R A L S U R G I C A L TECHNIQUES
29. Belt - Lo o p Ga st ro pex y
The Seromuscular Flap Is Advanced Through The “Belt Loop” Created In The
Abdominal Wall. The Stomach Should Be Held In Close Approximation To The Body
Wall As This Is Accomplished To Minimize Trauma To The Flap. The Flap Is Then
Sutured Back Into The Area It Originated From On The Stomach
G E N E R A L S U R G I C A L TECHNIQUES
30. C ircumco st al Ga st ropexy
A Seromuscular Flap Is Raised From The Pyloric Antrum Similar To The Belt-loop Gastropexy
Technique.
The Seromuscular Flap May Be Double Or Single Hinged. When A Single-hinged Flap Is Used, It Is
Based From The Lesser Curvature Of The Stomach And Undermined Below The Level Of The
Muscularis Layer, Taking Care Not To Penetrate The Gastric Lumen.
G E N E R A L S U R G I C A L TECHNIQUES
31. C ircumco st al Ga st ropexy
A 5- To 6-cm Incision Is Made Directly Over The Eleventh Or Twelfth Rib At The Level Of The
Costochondral Junction.
A Plane Of Blunt Dissection Is Then Established Circumferentially In Close Association With The Rib.
Care Must Be Taken To Avoid Creation Of Pneumothorax Or Fracture Of The Rib
G E N E R A L S U R G I C A L TECHNIQUES
32. C ircumco st al Ga st ropexy
The Seromuscular Gastric Flap Is Then Passed Cranial To Caudal Through The Tunnel Surrounding The Rib
Stay Sutures Placed In The Leading Edge Of The Flap Facilitate Passage Around The Rib.
The Seromuscular Flap Is Sutured Back To Its Origin Using 2-0 Or 3-0 Absorbable Suture Material.
G E N E R A L S U R G I C A L TECHNIQUES
33. C ircumco st al Ga st ropexy
Make A Single- Or Double-layered Hinged Seromuscular Flap
In The Pyloric Antrum.
G E N E R A L S U R G I C A L TECHNIQUES
34. C ircumco st al Ga st ropexy
Make An Incision Over The Eleventh Or Twelfth Rib At The
Level Of The Costochondral Junction.
G E N E R A L S U R G I C A L TECHNIQUES
35. C ircumco st al Ga st ropexy
Form A Tunnel Under The Rib Using A Carmalt Clamp Or Hemostat.
G E N E R A L S U R G I C A L TECHNIQUES
36. C ircumco st al Ga st ropexy
Pass The Gastric Antral Flap Craniodorsal Under The Rib And Suture It To The
Original Gastric Margin Or To The Other Flap.
G E N E R A L S U R G I C A L TECHNIQUES
37. Ga st ro colopexy
Creation Of A Suture Line Between The Greater Curvature Of The Stomach And The Transverse
Colon Has Been Described To Prevent Recurrence Of Gastric Dilatation Volvulus.
Gastrocolopexy As Reported Does Not Include Incision Into The Seromuscular Layer Of Either The
Stomach Or The Colon; Instead, The Surfaces Are Scarified And Then Apposed With Nonabsorbable
Sutures. Whether A Permanent Adhesion Is Created Is Unknown.
G E N E R A L S U R G I C A L TECHNIQUES
38. Py lo ro my oto my And Py lo ro pla sty
Pyloric Surgical Techniques Are Focused On Removing Outflow Obstruction And
Normalizing Gastric Outflow.
Several Techniques Have Been Described, Including The Fredet-ramstedt
Pyloromyotomy, Heineke-mikulicz Pyloroplasty, And Y-u Pyloroplasty.
G E N E R A L S U R G I C A L TECHNIQUES
39. Fredet - R a mst edt Py lo ro my oto my
Fredet-ramstedt Pyloromyotomy Is Performed By Making A Longitudinal Incision Through Serosa And
Muscularis Of The Ventral Pylorus.
The Incision Should Be Centered Over The Pylorus And Extend 1 To 2 Cm Orad And Aborad.
When Performed Correctly, The Gastric Mucosa Is Not Penetrated; However, Its Submucosal Surface
Should Protrude Through The Incision. This Partial-thickness Incision Is Left Open, Permitting
Enlargement Of The Pylorus In Cases In Which Restriction Is Limited To The Serosa Or Muscularis.
Because Pyloromyotomy Does Not Allow Visualization Of The Gastric Mucosa, Relieve Restrictions
Associated With Mucosal Or Submucosal Disease, Or Provide A Means For Full-thickness Biopsy Of
The Stomach Wall, Its Use Is Limited.
G E N E R A L S U R G I C A L TECHNIQUES
40. Fredet - R a mst edt Py lo ro my oto my
Myotomy Is Considered For Pyloric Widening If
Pyloric Musculature Is Thickened But Mucosa
And Submucosa Are Normal.
G E N E R A L S U R G I C A L TECHNIQUES
41. Fredet - R a mst edt Py lo ro my oto my
A Longitudinal Incision Is Made Through The
Muscular Layer, And All Muscular Fibers Are
Transected.
G E N E R A L S U R G I C A L TECHNIQUES
42. Fredet - R a mst edt Py lo ro my oto my
When Properly Performed, Mucosa And
Submucosa Bulge Through The Incision.
G E N E R A L S U R G I C A L TECHNIQUES
43. Heineke - M ikulicz Py lo ro pla sty
Heineke-mikulicz Pyloroplasty Is Similar To Pyloromyotomy In That A Longitudinal Incision Is Made In
The Ventral Surface Of The Pylorus; However, The Incision Is Created Full Thickness And Then Closed
Transversely.
Stay Sutures Can Be Placed In The Middle Of Either Side Of The Longitudinal Incision And Retracted
To Reorient The Tissues For The Transverse Closure; Alternatively, Stay Sutures Can Be Placed At Each
End Of The Incision And Pulled Together To Provide The Same Effect.
Closure Is Achieved With 2-0 Or 3-0 Absorbable Monofilament Suture Material In An Interrupted
Appositional Pattern.
Heineke-mikulicz Pyloroplasty Permits Full-thickness Gastric Wall Biopsy And Resection Of Small
Masses Or Thickened Tissues Along The Incision.
G E N E R A L S U R G I C A L TECHNIQUES
44. Heineke - M ikulicz Py lo ro pla sty
A Full-thickness Longitudinal Incision, Centered Over The
Pylorus And Extending 1 To 2 Cm Orad And Aborad, Is Made.
The Pyloric Area Is Inspected Visually, And Tissue Is Taken
For Histopathologic Examination.
G E N E R A L S U R G I C A L TECHNIQUES
45. Heineke - M ikulicz Py lo ro pla sty
Stay Sutures Placed At The Midpoint Along Each Side Of The
Incision Are Retracted. The Incision Is Closed Transversely
Using An Appositional Closure Pattern.
Finished Closure Of The Pyloroplasty.
G E N E R A L S U R G I C A L TECHNIQUES
46. Y- U Py lo ro p la sty
Y-U Pyloroplasty Increases Pyloric Outflow Tract Diameter By Advancing A Portion Of The Pyloric
Antrum Into The Region Of The Pyloric Sphincter.
A Y-shaped Full-thickness Incision Is Centered Over The Pylorus. The Fullthickness Incision For The
Body (Or Main Stem) Of The Y Is Made Through The Ventral Antimesenteric Aspect Of The Duodenum
And Pyloric Sphincter, And The Incisions For The Arms Of The Y Extend Into The Pyloric Antrum.
The Arms Of The Y Should Curve Slightly To Form A U-shaped Flap Instead Of A Sharp V To Maximize
Vascular Supply To The Flap.
G E N E R A L S U R G I C A L TECHNIQUES
47. The Pyloric Region Is Examined To Verify That Patency Will Be Maintained After Closure.
A Full-thickness Margin Of The Incision Is Harvested For Biopsy, And Mucosa And Submucosa Are
Resected As Needed.
The U-shaped Flap Is Then Advanced Forward, Using Stay Sutures At Its Tip, To The Base Of The Y
And Sutured Into The Most Aboral Portion Of The Incision At The Duodenum With 2-0 Absorbable
Monofilament Suture Material In An Appositional Pattern.
Y- U Py lo ro p la sty
G E N E R A L S U R G I C A L TECHNIQUES
48. Y- U Py lo ro p la sty
The Pylorus Is Identified And Isolated
Using Moistened Laparotomy Sponges.
The Full-thickness Y Incision Is Made. The Body
Of The (Y)Begins 1 To 2 Cm Aborad From The
Pylorus And Extends Through The Pylorus, And
The Arms Of The (Y) Extend Onto The Pyloric
Antrum.
After removal of tissue for biopsy, the curved center
of the (U) is advanced into the farthest extent of the
original incision and sutured into place using an
appositional pattern.
G E N E R A L S U R G I C A L TECHNIQUES
49. Ga st ro duodenal A na st o mosis
Pylorectomy With Gastroduodenal Anastomosis (Billroth I) Is Performed In Animals With Pyloric Outflow
Obstruction That Cannot Be Treated With Routine Pyloroplasty Techniques.
Indications Include Neoplasia Confined To The Pyloric Region, Ulceration Of The Outflow Tract, And Some Cases
Of Pyloric Hypertrophy. When Neoplasia Is Suspected, A 1- To 2-cm Margin Of Normal Tissue Should Be Removed
With The Abnormal Tissue.
Pyloric Resection Is Technically More Challenging Than Other Techniques Involving The Pylorus And Requires
Detailed Knowledge Of Regional Anatomy. The Bile Duct, Pancreatic Ducts, And Vascular Supply To The Stomach
And Duodenum Must Be Identified Before Any Surgical Excision
G E N E R A L S U R G I C A L TECHNIQUES
50. Ga st ro duodenal A na st o mosis
The Bile Duct Is Best Identified By Manual Expression Of The Gallbladder: Bile Can Be Detected As It Descends
Through And Dilates The Bile Duct As It Approaches The Duodenum.
Stay Sutures Are Placed In The Duodenum And Stomach To Facilitate Retraction And Minimize Potential Leakage.
Atraumatic Tissue Forceps Are Used Proximal And Distal To The Site Of Resection To Minimize Leakage Of
Gastrointestinal Contents.
The Hepatogastric Ligament Can Be Transected To Facilitate Caudoventral Retraction Of The Pylorus; However, Care
Should Be Taken To Avoid Bile Duct Transection Deep And Lateral To This Area.
G E N E R A L S U R G I C A L TECHNIQUES
51. Ga st ro duodenal A na st o mosis
A Minimum Of 5 To 10 Mm Of Healthy Tissue Should Be Maintained Between The Duodenal Level Of Excision
And The Opening Of The Bile Duct To Prevent Inadvertent Damage Or Obstruction.
Branches Of The Right Gastric And Right Gastroepiploic Blood Vessels Supplying The Area To Be Resected Are
Ligated And Transected.
Omental And Mesenteric Attachments Are Ligated And Divided.
After Making Sure The Area Is Packed Off From The Rest Of The Abdomen With Laparotomy Sponges, The Pylorus
Is Removed With Metzenbaum Scissors Or A Scalpel.
G E N E R A L S U R G I C A L TECHNIQUES
52. Ga st ro duodenal A na st o mosis
If A Significant Discrepancy In Lumen Diameter Is Created By This Resection, The Surgeon May Choose To Incise
The Antimesenteric Border Of The Duodenum To Increase Its Diameter Or Close A Portion Of The Gastric Antrum To
Narrow Gastric Diameter To Facilitate Anastomosi
G E N E R A L S U R G I C A L TECHNIQUES
53. Ga st ro duodenal A na st o mosis
End-to-End Anastomosis Of The Stomach And Duodenum Is Performed With A One- Or Two-layer Appositional
Pattern Using A Simple Interrupted Or Simple Continuous Pattern Of 2-0 Or 3-0 Absorbable Monofilament Suture.
If Biliary Obstruction From Regional Swelling Is A Concern, The Common Bile Duct And Its Opening Can Be
Stented With A Piece Of Red Rubber Catheter, Which Is Secured To The Interior Of The Duodenum With Absorbable
Suture, Before The Anastomosis Is Completed.
The Prognosis After Pylorectomy And Gastroduodenostomy Depends On The Underlying Disease
G E N E R A L S U R G I C A L TECHNIQUES
54. Ga st ro duodenal A na st o mosis
Partial Gastrectomy With Gastrojejunal Anastomosis (Billroth II) May Be Performed When Gastric Neoplasia
Precludes End-to-end Anastomosis Of The Pyloric Antrum To The Duodenum.
Steps To Perform Gastrojejunal Anastomosis Are Similar To Gastroduodenal Anastomosis, Including Careful
Identification Of The Regional Anatomy And Extent Of The Lesion.
In This Technique The Resulting Openings Into The Stomach And Duodenum Are Closed, And A Loop Of Jejunum Is
Anastomosed To The Greater Curvature Of The Stomach In A Side-to-side Fashion.
Cholecystoenterostomy Is Often Required To Permit Biliary Flow.
Prognosis Is Very Poor After This Procedure.
G E N E R A L S U R G I C A L TECHNIQUES
55. Ga st ro duodenal A na st o mosis
P y l o re c t o m y Wi t h E n d - t o - e n d G a s t ro d u o d e n o s t o m y
The Offending Section Of The Pylorus Is Resected
Along The Gastric And Duodenal Margins.
G E N E R A L S U R G I C A L TECHNIQUES
56. Ga st ro duodenal A na st o mosis
P y l o re c t o m y Wi t h E n d - t o - e n d G a s t ro d u o d e n o s t o m y
The Resulting Incisions Are Evaluated For
Comparable Circumferences.
G E N E R A L S U R G I C A L TECHNIQUES
57. Ga st ro duodenal A na st o mosis
P y l o re c t o m y Wi t h E n d - t o - e n d G a s t ro d u o d e n o s t o m y
If The Gastric Margin Is Of A Larger
Circumference Than The Duodenal Margin, The
Gastric Margin Is Reduced In Circumference From
The Lesser Curvature Toward The Greater
Curvature With A Simple Interrupted Or
Continuous Appositional Pattern; An Additional
Inverting Pattern May Be Applied If Feasible.
G E N E R A L S U R G I C A L TECHNIQUES
58. Ga st ro duodenal A na st o mosis
P y l o re c t o m y Wi t h E n d - t o - e n d G a s t ro d u o d e n o s t o m y
The Duodenal And Gastric Margins Are Apposed
With A Single-layer Simple Interrupted
Appositional Pattern.
G E N E R A L S U R G I C A L TECHNIQUES
59. G E N E R A L S U R G I C A L TECHNIQUES
Ga st ro duodenal A na st o mosis
P y l o re c t o m y Wi t h E n d - t o - e n d G a s t ro d u o d e n o s t o m y
Alternatively, This Procedure Can Be Performed
With Stapling Equipment. The End-to-end
Anastomosis Is Achieved When The Circular
Stapling Device Is Made To Exit The Gastric
Remnant Through The Stoma Left Open At The
Greater Curvature Margin Of The Gastric
Resection.
60. G E N E R A L P O S T O P E R A T I V E C O N S I D E R A T I O N S
After Gastric Surgery, Fluid Therapy Is Continued Until The Animal Is Eating And Drinking Adequately.
Oral Intake Of Food And Water May Be Initiated As Early As 12 Hours After Surgery In Patients That Are
Not Actively Vomiting, Regardless Of The Surgical Procedure Performed.
If Vomiting Is Present, Investigation Of The Cause Is Indicated.
61. G E N E R A L P O S T O P E R A T I V E C O N S I D E R A T I O N S
If Loss Of Intestinal Motility Is Suspected, Electrolytes (Particularly Potassium And Magnesium) Should
Be Evaluated And The Patient Examined For Evidence Of Peritonitis Or Obstruction.
If No Underlying Cause Can Be Detected, Treatment With A Prokinetic Agent Such As Metoclopramide
Or Cisapride May Be Effective To Resolve The Ileus.
62. G E N E R A L P O S T O P E R A T I V E C O N S I D E R A T I O N S
In Severe Cases Of Ileus, A Nasogastric Tube May Be Used To Intermittently Decompress The Stomach
And Trickle Feed The Patient, Which May Stimulate Gastric Motility
When Vomiting Or Regurgitation Is Noted, Administration Of Proton Pump Inhibitors Or Histamine2
(H2) Receptor Antagonist Agents Reduces Production Of Gastric Acid And May Decrease The Risk For
Damage To The Esophagus.
63. G E N E R A L P O S T O P E R A T I V E C O N S I D E R A T I O N S
Animals That Are Anorexic Before Surgery Or Anticipated To Have Prolonged Anorexia After Surgery
Should Have Some Form Of Feeding Tube Placed To Supplement Their Caloric Intake.
The Specific Route Of Feeding Is Based On The Underlying Disease Process And The Surgical Procedure
Performed.
If A Tube Feeding Is Predicted, A Nasoenteric Tube Can Be Placed During Surgery, With Manual
Advancement Of The Tube From The Stomach Into The Duodenum Assisted By The Surgeon.