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Gastrointestinal Veterinary Talk, Part 2
- 1. ο Important anatomic points and helpful hints ο Vasculature ο Gastric cardia β palpation of stomach tube ο Fundus β greater curvature area of necrosis ο Antrum β location of gastropexy incision ο Pylorus I.D. by decrease in luminal diameter more than palpation ο Gastric wall β βslipping membranesβ
- 2. ο Proximal duodenum ο Duodenal papilla ο Major β bile duct and pancreatic duct ο Minor β accessory pancreatic duct
- 3. ο Proximal duodenum ο Duodenal papilla ο Major β bile duct and pancreatic duct ο Minor β accessory pancreatic duct
- 4. ο Proximal duodenum ο Duodenal papilla ο Major β bile duct and pancreatic duct ο Minor β accessory pancreatic duct
- 5. ο Duodenocolic ligament ο Holds distal descending duodenum to dorsal body wall ο Challenge to running bowel ο Easily transected if needed ο Difficult to suture adjacent duodenum if not transected
- 7. ο Full abdominal exploration - βOpen them upβ ο Be systematic ο Be gentle especially with linear foreign body
- 8. ο My approach ο Liver ο Stomach ο Duodenum and right pancreatic limb ο Right kidney and adrenal ο Jejunum, Ileum and Colon ο Left kidney and adrenal ο Bladder ο +/- Gall bladder expression ο +/- Opening omental bursa and left pancreatic limb
- 9. ο Surgical options ο Gastrotomy ο Gastropexy ο Gastrectomy ο Gastric resection anastomosis
- 10. ο Gastrotomy ο Location β ventral surface equidistance from greater and lesser curvature
- 11. ο Gastrotomy ο Minimize contamination ο Pack off abdomen ο Stay sutures ο Suction helpful ο Towel ready to receive what comes out ο Orogastric tube prior to entering lumen if fluid filled
- 12. ο Gastrotomy ο Minimize contamination ο Pack off abdomen ο Stay sutures ο Suction helpful ο Towel ready to receive what comes out ο Orogastric tube prior to enter lumen if fluid filled
- 13. ο Gastrotomy ο Stab incision ο Extend with scissors parallel to curvatures ο Separation of layers ο Mucosa-submucosa ο Muscularis-serosa
- 14. ο Gastrotomy ο Single or double layer closure ο I typically close in two layers using 3-0 PDS ο Mucosa-submucosa β simple continuous ο Serosa-muscularis β interrupted lembert ο No leak test ο The stomach wants to heal
- 15. ο Gastropexy ο Location ο Technique ο I only perform incisional ο 2-4 cm from pylorus ο Ventral midpoint of antrum ο Avoid lumen penetration ο Separation of layers ο +/- stay sutures
- 16. ο Gastropexy ο Location ο Technique ο Be aware of diaphragm = pneumothorax ο Glistening fascia ο Transverse incision not too dorsal ο Suture deepest to most superficial ο 2-0 PDS two continuous strands joined at most ventral aspect of pexy ο Avoid lumen penetration
- 18. ο Gastrectomy ο Indications ο Necrosis - GDV ο Neoplasia ο Ulcer with perforation ο Rupture
- 19. ο Gastrectomy ο Gastric viability ο Color ο Gray = bad ο Purple = likely OK ο Red = good ο Thickness ο Temperature ο Bleeding on cut serosal surface
- 20. ο Gastrectomy ο Technique ο Stapled β TA or GIA ο Cut and sew, cut and sew, etc. ο Lots of stay sutures ο Technically challenging ο Contamination ο Tissue thickness in intestinal forceps ο Invagination ο Serosa to serosa healing ο Easy ο No contamination
- 21. ο Gastric R-A ο Indications ο Neoplasia ο Perforating ulcer ο Hand sewn ο Single layer ο Complicated technically ο Lots of potential complications
- 22. ο Enterotomy and resection-anastomosis ο Appositional best ο Maintains luminal diameter ο Less fibrosis
- 23. ο Simple interrupted vs simple continuous ο Staples vs sutures ο Compendium 2000 ο Simple continuous better apposition ο Faster ο Staples β TA 35 (0.51 diameter close to 4.8mm x 3.4mm) ο Place 3 stay sutures and staples in between
- 24. ο What do I do? ο Ligaclips for vascular ligation ο Maintain as much mesoduodenum or mesojejunum as possible ο Suture terminal vessels
- 25. ο What do I do? ο SI with 3-0 or 4-0 PDS ο Take healthy bites ο 3-mm spacing ο Donβt worry about mucosal eversion unless severe ο Always leak test
- 26. ο Enterotomy ο Pack off to minimize contamination ο Surface to receive what is being removed ο Have everything ready ο Needle drivers ο Suture ο Thumb forceps ο Doyens or assistant ο No manipulation of vasculature
- 27. ο Enterotomy ο Longitudinal incision to transverse closure ο Increases luminal diameter ο Only used if small incision (i.e. biopsy) ο Generally not applicable at site of foreign body excision. ο Good for closure of site to cut string
- 28. ο BE GENTLE especially with small thread foreign bodies ο Typically hung in pylorus = gastrotomy ο Typically require multiple enterotomies ο Releasing and removing ο Minimize ο Critically evaluate viability ο Mesenteric border ο Duodenum adjacent to ligament ο Consider re-enforcements
- 29. ο Indications ο Intussusception ο Neoplasia ο Foreign body
- 30. ο Special considerations ο Contamination issues ο Gram neg. and anerobes ο Vasculature dissection more tedious ο Separation of layers ο Luminal disparity ο Oblique transection ο Variable tissue spacing ο Spatulation ο End-to-side
- 31. ο Special considerations ο Contamination issues ο Gram neg. and anerobes ο Vasculature dissection more tedious ο Separation of layers ο Luminal disparity ο Oblique transection ο Variable tissue spacing ο Spatulation ο End-to-side
- 32. ο Special considerations ο Contamination issues ο Gram neg. and anerobes ο Vasculature dissection more tedious ο Separation of layers ο Luminal disparity ο Oblique transection ο Variable tissue spacing ο Spatulation ο End-to-side
- 33. ο Indications ο Neoplasia ο Cecal inversion ο Technique ο Ileocecal and accessory cecocolic folds transected ο TA stapler very handy ο Simple interrupted
- 34. ο Indications ο Neoplasia ο Cecal inversion ο Technique ο Ileocecal and accessory cecocolic folds transected ο TA stapler very handy ο Simple interrupted
- 35. ο Indications ο Neoplasia ο Cecal inversion ο Technique ο Ileocecal and accessory cecocolic folds transected ο TA stapler very handy ο Simple interrupted
- 36. ο Indications ο Neoplasia ο Cecal inversion ο Technique ο Ileocecal and accessory cecocolic folds transected ο TA stapler very handy ο Simple interrupted
- 37. ο Closure re-enforcement ο Omentum ο Generally will attach without tacking. ο Tacking may speed up the process ο Serosal patching ο Time consuming ο I perform if I am worried
- 38. ο Closure re-enforcement ο Omentum ο Benefits ο Increased blood flow ο Rapid fibrin seal ο Generally will attach without tacking. ο Tacking may speed up the process ο Serosal patching ο Time consuming ο I perform if worried
- 39. ο Nutritional support ο Jejunostomy tube
- 40. ο Explore again to make sure ο Full thickness BIOPSY ο Stomach ο Duodenum and jejunum ο 4-mm skin punch biopsy ο (+/-) Ileum ο Donβt biopsy colon unless essential
- 41. ο Lavage ο Warm saline in water bath or microwave ο 200-300 ml/kg ο I use: ο Small dogs and cats β 1-2 liters ο Medium dogs β 2-3 liters ο Large dogs β 4-6 liters ο Keep flushing until clear ο Remove blood clots
Editor's Notes
- Compendium 2000Author β Bradley CoolmanSimple continuous better appositionFasterStaples β TA 35 (0.51 diameter close to 4.8mm x 3.4mm)Place 3 stay sutures and staples in between
- LavageWarm water bath200-300ml/kg recommended. We typically use:1-2 liters β small dogs and cats2-3 liters β medium dogs4-6 liters β large dogsKeep flushing until fluid is clear, no active bleeding and all blood clots removed. Contaminated fluid left in the abdomen can complicate healing process especially if associated with significant volumes of blood or bile.