Confidence and Consistency During Abdominal Procedures
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Max Bush, VMD, DACVS-SA The goal of this lecture is to communicate techniques for performing a laparotomy, for such conditions as GI foreign bodies, GI biopsies, explore with biopsies, and splenectomy. It will focus on the appropriate set up and preparation for abdominal surgery, including instrumentation and table set up; a consistent and reliably repeatable method for exploring the entire abdomen; and a review of techniques to avoid common complications.
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Confidence and Consistency During Abdominal Procedures
- 1. MAXWELL BUSH, VMD DIPLOMATE, AMERICAN COLLEGE OF VETERINARY SURGEONS PERFORMING SUCCESSFUL LAPAROTOMIES Upstate Veterinary Specialties Continuing Education Fall 2018
- 2. WWW.UVSONLINE.COM Preparation Instrumentation Procedure Questions New @ UVS LEARNING OBJECTIVES 10/23/2018
- 3. WWW.UVSONLINE.COM Have all instruments been pulled/sterilized Laminated checklists General pack should include: Metzenbaum scissors (delicate) Non-crushing forceps (Debakey or Cooley) for bowel or other delicate viscera Babcock forceps are useful for gentle but secure traction Poole suction (x2) Self-retaining retractors Balfour or Gossett Punch biopsies SURGICAL SET UP 10/23/2018
- 4. WWW.UVSONLINE.COM Shaved from midthorax to pubis Dirty scrub in prep area, followed by 5 minute sterile scrub Pre-operative antibiotics should be on board 30 mins prior to cut PATIENT PREPARATION - LAPAROTOMY 10/23/2018
- 5. WWW.UVSONLINE.COM Instruments laid out in neat, organized fashion Always same layout/order Minimizes fishing Sponge count Radio-opaque sponges and lap-pads are ideal Set aside clean instruments for closing Brown-Adson forceps, needle drivers, suture scissors New Poole suction tip TABLE PREP 10/23/2018
- 9. WWW.UVSONLINE.COM Developed in human medicine to prevent adverse events in surgery Excellent method of developing consistency, and providing best care Prepared prior to surgery but reviewed in OR prior to starting procedure Addresses Anesthesia safety Surgical infection Communication SURGICAL SAFETY CHECKLIST 10/23/2018
- 10. WWW.UVSONLINE.COM Patient identification Surgical procedure to be performed Side/Site SURGICAL SAFETY CHECKLIST – WHAT TO INCLUDE 10/23/2018
- 11. WWW.UVSONLINE.COM Patient specific risk factors Allergies Medications, suture Comorbidities Immune compromised Coagulopathic Cardiac disease Are appropriate interventions prepared Emergency drugs Appropriate equipment Ventilation available SURGICAL SAFETY CHECKLIST 10/23/2018
- 12. WWW.UVSONLINE.COM Verify that all relevant diagnostics are available and displayed Imaging reports Previous surgery reports Radiographs or CT images Labwork Coag testing BG Recent CBC/Chem SURGICAL CHECKLIST 10/23/2018
- 13. WWW.UVSONLINE.COM Reference materials Anatomy book Model Surgical textbook What sample are needed Shopping list SURGICAL SAFETY CHECKLIST - OPTIONAL 10/23/2018
- 15. WWW.UVSONLINE.COM Ventral midline incision from xyphoid to pubis In male dogs, take incision to just cranial to prepuce, curving/slanting slightly towards the surgeon Skin incision with #10 blade Cautery through SQ fat THE APPROACH 10/23/2018
- 17. WWW.UVSONLINE.COM Remove falciform ligament, via traction, or via electrocautery Traction is much faster, but sometimes leaves several hemorrhagic vessels Cranially, where the falciform meets the xyphoid, it is helpful to clamp across pedicle to crush the fat and isolate the vessel 10/23/2018
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- 19. WWW.UVSONLINE.COM Begin the Explore Free fluid? Start exploration at the cranial extent of the abdomen (This is my approach, it is not mandatory, but whatever approach you choose, make sure that it is all inclusive, and that you repeat it every time) 10/23/2018
- 20. WWW.UVSONLINE.COM Elevate the xyphoid, and lower the surgical lamp Examine liver for Discoloration, plaques, nodules Edges sharp or blunted Palpate (right hand) Beginning with left lateral Gall Bladder Gently squeeze to assess patency LIVER 10/23/2018
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- 23. WWW.UVSONLINE.COM Reach across and cranially, behind liver to the esophageal hiatus Identify the proximal extent of the stomach Important landmark for GDV surgery Palpate the Cardia, Fundus, and Body, working towards the antrum and pylorus Grasp the duodenum and elevate GI TRACT 10/23/2018
- 25. WWW.UVSONLINE.COM Examine the descending duodenum and right limb of the pancreas Examine the CBD as it enters the duodenum Dilation, masses Duodenocolic ligament Examine the right kidney and adrenal gland 10/23/2018
- 30. WWW.UVSONLINE.COM 4 Ps Color (Pink/Purple/Grey/Black) Pulses (Mesentery and arcuate vessels) Peristalsis Palpation (thickness/texture) EVALUATING THE BOWEL 10/23/2018
- 31. WWW.UVSONLINE.COM Isolate the desired segment of bowel Incise with a NEW 15 blade Extend incision with Metz Patiently extract foreign material Enterotomy should be aboral to foreign body Minimize the # of enterotomies performed Each incision represents a potential dehiscence GI BIOPSIES OR ENTEROTOMY 10/23/2018
- 32. WWW.UVSONLINE.COM I will usually attempt to milk the strand back to the point of anchorage Minimize or avoid enterotomy Evaluate bowel after clearing the foreign material Gut appearance will often improve drastically over 5-10 min Sweatshirt hood drawstring analogy LINEAR FOREIGN MATERIAL 10/23/2018
- 33. WWW.UVSONLINE.COM Have an assistant place mild tension on the enterotomy to align edges and remove slack Close with either SI or SC, ensuring that submucosa is include in each bite Handle excessive mucosa either by trimming or slightly inverting tissue edges Sutures should be snug but not crushing Leak check with a 6cc syringe and 25g needle, and gentle pressure CLOSING THE GI 10/23/2018
- 38. WWW.UVSONLINE.COM Gloves/Instrument change Copious lavage Removes residual debris Removes excess hemorrhage Warms the patient Sponge count Assistant counts and reports discarded sponges FIRST FINISHING 10/23/2018
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- 46. WWW.UVSONLINE.COM We are excited to introduce Dr. Joe Palamara EXCITING NEW DEVELOPMENTS FOR UVS SURGERY TEAM
- 47. WWW.UVSONLINE.COM MINIMALLY-INVASIVE SERVICES Soft tissue Thoracoscopy Explore Lung lobectomy Pericardiectomy Thoracic duct ligation Laparoscopy Explore Uncomplicated gall bladder mucocele (GBM) Adrenal mass, right or left, without caval invasion Sublumbar lymph node extirpation Laparoscopic-assisted procedures Gastropexy Gastrointestinal biopsies (ie IBD, LSA) Cystotomy (solitary cystic calculi)
- 48. WWW.UVSONLINE.COM MINIMALLY-INVASIVE SERVICES Orthopedic Arthroscopy Shoulder Elbow Stifle Tarsus Minimally-invasive fracture repair Long bone fractures – radial, tibial; humerus, femur Physeal (Salter Harris) fractures Sacroiliac separation-luxation
- 49. T-cell lymphoma Lymphocytic hepatitis Necrotizing hepatitis with Cu Granulomas Periportal T-Cell infiltrate Portovenous hypoperfusion (Shunt )
- 50. WWW.UVSONLINE.COM 9 yo MC Poodle Mix progressive alopecia x 1-2 months progressive muscle wasting x 1-2 months Polyuria noted since April 2018 Dietary indiscretion / polyphagia - bird seed ACTH stimulation test 6/21/18 - increase in post ACTH progesterone US - left adrenal gland mass (2.1 L x 1.6 H cm) with small right adrenal gland Suspected Atypical Cushing’s – Adrenal Dependent Dipstick positive for protein 6/21/18 Negative urine culture 6/21/18 Mild hypoalbuminemia and hypercholesterolemia noted 6/21/18 Hypertension Protein Losing Nephropathy CASE STUDY – OBIE BEAR LONGSTREET
- 51. WWW.UVSONLINE.COM Surgery was recommended: Left adrenalectomy Risk factors for surgery and anesthesia: Hypertension Thromboembolic event Poor healing response Recommended laparoscopic approach: Left adrenal gland is well visualized laparoscopically Tumor was relatively small, and non-invasive Minimize trauma/recovery time Reduce and relocate incisions to reduce risk of dehiscence ADRENAL DEPENDENT ATYPICAL CUSHING’S
- 59. WWW.UVSONLINE.COM 1 month post op PU/PD Energy Normal renal values and resolution of proteinuria Resolution of hypertension 2 months post op Doing well off of all medications Cushing’s dz considered cured FOLLOW UP 10/23/2018
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- 61. WWW.UVSONLINE.COM JOSEPH PALAMARA, DVM, DACVS-SA Rotating Internship, Small Animal Medicine and Surgery – Animal Medical Center, NY, NY Residency, Small Animal Surgery – VCA Animal Specialty Center, Yonkers, NY Diplomate, American College of Veterinary Surgery – Small Animal
- 63. WWW.UVSONLINE.COM ‘KUBO” ARTHROSCOPY Fragmented coronoid Full thickness cartilage erosion of the medial coronoid Full thickness cartilage erosion of the medial humeral condyle “kissing lesion” Subchondral bone eburnation (exposed subchondral bone) Fragment Removal Hand burr Motorized shaver Curettage Microforage
- 64. WWW.UVSONLINE.COM “ROSIE” 6 MONTH F LAB HBC Polytrauma – lung contusions Right sacroiliac luxation
- 70. WWW.UVSONLINE.COM “ROSIE” RIGHT HIND LEFT HIND • Smaller incisions • Decreased pain • Purported shorter hospitalization 3cm incision 2cm incision 2.5cm incision
Editor's Notes
- Splenectomy: hemoclips or LDS stapler, suture, Lots of different size clamps, suction, lap pads, bucket GI biopsies: 3 or 4mm punch biopsy, fine suture (4-0 or 5-0 PDS or monocryl) Enterotomy: #15 blade, doyens,
- Laminated picture of the appropriate instrument layout is posted on OR wall, to help assistant with table set up
- The aim of the programme is to harness political commitment and clinical will to address important safety issues, including inadequate anaesthetic safety practices, avoidable surgical infection and poor communication among team members. These have proved to be common, deadly and preventable problems in all countries and settings. My goal in using this is to
- An specific checklist has to be designed for each particular hospital, but there are a few key components that should be included
- It is important to have this information readily accessible, either pulled up on a computer monitor or taped to the wall Important to know about previous surgeries such as gastropexy, to avoid injuring a prior repair, and to be able to distinguish pathology from expected scar, A healed enterotomy or anastomosis site can often resemble GI neoplasia Knowing what is expected avoids time wasted exploring a normal structure For cystotomies, radiographs or ultrasound with stone count completed if possible, to help ensure complete urolith removal GI foreign bodies, know #, shape, and location of material Beyond having this because it is important for decision making, it is also important to have this in case something goes wrong, in order to prove due diligence in preparing
- Cultures, Biopsies,
- Approach Ventral midline incision from xyphoid to pubis, or at least halfway between pubis and umbilicus In male dogs, I take incision to just cranial to prepuce, curving slightly towards me in case incision must be extended around prepuce Skin incision with blade, followed by electrocautery through SQ fat, spreading the fat on midline as you dissect in order to expose the linea Do not elevate, remove SQ fat; fat is usually denser/deeper caudal to umbilicus
- Start linea incision with scalpel (new blade) just cauda to the xyphoid, painting through midline until a small opening is observed; falciform fat will be visible I extend the incision caudally with a #15 scalpel blade, using Debakey forceps as a groove director Easy to remain straight and on midline Less tissue trauma compared to cutting through with mayo scissors (crushing) Helps to ensure abdominal viscera are protected
- Begin explore If there is any free fluid, suction the abdomen, quantify the fluid and obtain a culture if applicable Start exploration at the cranial extent of the abdomen (This is my approach, it is not mandatory, but whatever approach you choose, make sure that it is all inclusive, and that you repeat it every time
- Elevate the xyphoid and visually inspect the liver Look for discoloration, plaques, nodules, examine the edges for sharpness Palpate (right hand) all of the lobes beginning with left lateral and working towards yourself Examine gall bladder, gently squeeze to assess patency – do not have to express the gall bladder entirely
- Reach across and cranially, deep to the liver, along left body wall until you reach the esophageal hiatus. This is also a useful technique to know when performing GDV surgery. Having identified the proximal extent of the stomach feel for any foreign material within the Cardia, fundus, and Body of the stomach working your way towards the pyloric antrum. Reach down the nearside body wall to grasp the duodenum and elevate it - this will bring the pylorus into better view and allow for more thorough examination junction
- Examine the descending duodenum and right limb of the pancreas - follow the duodenum as for distally as possible before it reaches the caudal duodenal flexure which can be difficult to expose the duodenocolic ligament lies at the flexure, and tethers the duodenum to the colon and body wall; it can be partially or completely transected as needed to help exteriorize the duodenum, where many foreign body obstructions can cause damage use this opportunity to examine the right kidney and if possible the right adrenal gland
- identify the jejunum and gently begin exteriorizing bowel until the Digital interior can be laid out like a fan - in general, the entire to jejunum and ileocolic jxn can be exteriorized with no tension this allows for excellent visual inspection and palpation of the bowel and mesenteric lymph nodes and the removal of viscera from the abdomen makes examination of the deeper structures easier Replace the jejunum gently, ensuring that no kinking or twisting has occurred - in general, DJ will attempt to we settle itself in the appropriate position but it is essential to be aware of signs of potential torsion ( changes in color, texture)
- Reach over to the far side body wall and gently retrieve the spleen and pull it a midline position - mild elevation of the spleen above the level of the heart, Will assist in draining blood from the organ making it more manageable. Other techniques include a few drops of epinephrine on the capsule or gentle slapping
- reaching over again to the far body wall, And Gently elevate and examine the colon- retraction of the viscera with the mesocolon Will allow for inspection of the left kidney and adrenal gland examine the bladder, palpating the Wall for any areas of abnormal thickness, Or stones if there is a suspicion of uroliths the left limb of the pancreas is not always routinely examined but if necessary it can easily be exposed by entering the omental bursa and looking for the limb just caudal to the greater curvature of the stomach
- Glove and instrument change Important after any procedure in which there has been contamination eg opening a viscus or abscessation (liver, prostatic, tumor) Copious warm lavage – always test temp first Removes residual debris Removes excess hemorrhage Warms the patient Moistens the organs and facilitates a final check of the cavity Assists in allowing the viscera to resume their normal position and orientations At initiation of closure, ask the assistant to perform a sponge count, while you count the sponges remaining on the table Important that the assistant and you complete your counts first before announcing the number, in order to prevent an unconsciously biased answer. I always have the assistant announce their number first
- The linea should be closed with a strong, absorbable monofilament I use 0 PDS in most standard dog abdomens 2-0 for small dogs/cats, and 3-0 for toy/puppy I prefer to close the linea in simple continuous unless there is reason to doubt the integrity of the body wall I always suture right to left, but in large, overweight or deep chested dogs, I will sometimes close the cranial portion incision first with a couple of interrupted sutures, to avoid have to search for the edges at the end of a long continuous line In deep chested dogs, I will evacuate the air from the abdomen with suction priorto tying of the closing suture, to avoid pain from pneumoperitoneum
- Lavage the SQ space – remoisten the skin edges, flush away debris and desiccated tissue, improve handling Close the SQ layer in a simple continuous or continuous horizontal mattress Sometimes the caudal portions of the incision (caudal to the umbilicus, or adjacent to the prepuce) will require 2 SQ layers There is some controversy about closing the SQ space in celiotomies, but my training and recommendation is to close this layer The skin is a portion holding layer, relying on it to bear the tension of a closure increases the risk of dehiscence or skin edge necrosis SQ closure decreases dead space in the incision where seromas can accumulate Decreases the amount of healing that has to occur If there is concern about excessive suture material, a more rapidly absorbing material can be used, such as Monocryl
- Skin Continuous intradermal with 4-0 or 5-0 Monocryl or Simple continuous with nonabsorbable
- Clinical Assessment: Obie's clinical presentation is most consistent with Cushing's disease. Given the absence of a cholestatic hepatopathy, we were most suspicious of atypical Cushing's disease. An extended adrenal panel ACTH stimulation test demonstrated a marked elevation in his post ACTH progesterone levels, confirming those suspicions. His recheck abdominal ultrasound demonstrated a small mass / nodule in his left adrenal gland with a small right adrenal gland. This pattern fits with adrenal dependent atypical Cushing's disease. I discussed various treatment options for Obie's Cushing's disease including adrenalectomy, trilostane or mitotane. Herbal supplements (melatonin and lignans) could be considered but I generally find them ineffective to manage patients with significant clinical signs of Cushing's disease. For now, Ms. Longstreet does not wish to pursue surgery but she is considering medical management. Technically, atypical Cushing's disease should respond best to mitotane, however, adrenal tumors are generally fairly resistant to mitotane and more responsive to trilostane. For now, we discussed beginning therapy with trilostane (starting dose 10mg PO q 12) since it is generally easier to transition from trilostane to mitotane rather than vice versa. Ms. Longstreet will be getting back to us next week regarding her final therapeutic decision. Obie's recheck lab work also suggests that he has a protein losing nephropathy. This form of kidney disease is commonly associated with Cushing's disease. To confirm the presence of a PLN, we have recommended performing a pooled UPC. Unfortunately, If Obie has developed a PLN secondary to his Cushing's disease then he will require treatment of his PLN in addition to treatment of his Cushing's disease. Medical management of Cushing's disease does not typically correct a PLN.