Bovine GI Surgery

Question 1

Abomasal surgical disorders.

Answer 1

LDA (left displaced abomasum).
RDA (right displaced abomasum).
RVA (right abomasal volvulus/torsion).

Question 2

1. Classical sound on abdominal auscultation of LDA.
2. Methods of treatment of LDA.

Answer 2

1. Ping.
2. Conservative management e.g. casting and rolling.
   Surgical management:
   - open (conventional).
   - closed.
   - laparoscopic.

Question 3

Considerations for treatment of LDA.

Answer 3

Return and stabilise abomasum in a normal anatomical position.
Manage concurrent abdominal pathology.
Minimise additional risk.
Practicality - available handling facilities and available labour.
Economic cost-benefit.
Surgeon experience and familiarity with technique.

Question 4

Conservative management of LDA.

Answer 4

Casting and rolling.
Analgesia +/- spasmolytic.
Oral fluid therapy.
Calcium to improve motility.
Treatment of concurrent medical conditions:
- e.g.. metritis, ketosis.
Dietary management:
- High fibre, low starch.

Question 5

Process of casting and rolling as treatment of LDA.

Answer 5

Attach ropes ready to cast.
Cast cow into right lateral recumbency.
Roll onto back so abomasum floats up.
Rock gently from side to side while on back to deflate abomasum and help movement of gas into the intestines.
Continue to roll cow into left lateral recumbency and remain there for a further few minutes to allow gases to continue to escape.
Return to sternal recumbency.
- can give supportive therapy while here.

Question 6

Conservative management px.

Answer 6

40% success rate.
Monitor closely for return to function.
- signs will be more subtle than first time.

Question 7

Open (conventional) surgical correction methods of LDA.

Answer 7

Right sided paralumbar fossa (common).
Double sided paralumbar fossa (still commonly used).
Left sided paralumbar fossa.
(“Utrecht”) (less common in UK but occasionally useful),
Right paramedian (fairly common).

Question 8

Closed surgical correction methods of LDA.

Answer 8

Toggle-pin (common).
Blind fixation (not recommended).
Laparoscopy.

Question 9

Right paralumbar laparotomy.

Answer 9

For LDA.
With pyloropexy or omentopexy.
Return LDA to RHS and suture to RHS abdominal wall, in the hope that it will stabilise and carry on with normal function.

Question 10

1. Advantages of a right paralumbar laparotomy.
2. Disadvantages of rift paralumbar laparotomy.

Answer 10

1. Good visualisation of right abdomen.
   Low recurrence risk.
   Animal standing.
   Assistant not required.
2. Time.
   Cost.
   Requires arm long reach.
   Difficult if abomasal adhesions to the left body wall.

Question 11

Process of right paralumbar laparotomy.

Answer 11

Incise just caudal to last rib, at around middle of abdomen, incise the size of your bicep.
Reach caudally to the omental sling and dorsally, then cranially over the rumen to palpate the distended abomasum (like a balloon).
Insert 2 inch 14G needle attached to sterile tubing into the abomasum at the most dorsal point to remove gas. (Guarding as guiding through abdomen).
- takes time for gas to be removed.
Remove needle once all gas removed.
Reach across ventral body wall and grasp pylorus or lesser omentum on the midline then gently raise pylorus to the ventral margin of the incision, restoring near-ish normal anatomical position.
Exteriorise the abomasum through incision.
- “Sow’s ear” = lesser omentum.
- pylorus at the bottom.
Perform omentopexy or pyloropexy to anchor abomasum to right body wall.
- use thick dissolvable or non-dissolvable suture material e.g. vicryl size 0.
- suture pexy to peritoneum and transverse abdominal muscle at the cranial incision.
Perform routine abdominal and skin closure.

Question 12

Double sided paralumbar fossa approach to LDA process.

Answer 12

With pyloropexy or omentopexy.
As for unilateral RHS paralumbar fossa approach
But have 2 surgeons - second surgeon performs a simiultaneous paralumbar incision on LHS.
- then push down distended abomasum to release gas.
- then hands lessee omentum to RHS surgeon.
- abomasum is anchored on the right as before.

Question 13

1. Double sided paralumbar fossa approach to LDA advantages.
2. Double sided paralumbar fossa approach to LDA disadvantages.

Answer 13

1. Advantages as with right sided paralumbar fossa approach.
   Very good visualisation.
   Can break down adhesions
2. Requires 2 surgeons.
   Cost.
   Time.

Question 14

Left paralumbar laparotomy (Utrecht method) approach to LDA.

Answer 14

With abomasopexy.
Left flank paralumbar approach.
Decompress abomasum.
Exteriorise an area of abomasal fundus via incision.
Place 2 large stay sutures in dorsocranial aspect of abomasal fundus.
Take needles and abomasum right down to caudal abdomen of body wall.
Pass needles ventrally in abdomen to exit body wall to right of midline, caudal to sternum, avoiding veins.
Tie the two ends together with a surgeon’ knot.

Question 15

1. Left paralumbar laparotomy (Utrecht method) approach to LDA advantages.
2. Disadvantages for left paralumbar laparotomy (Utrecht method) approach to LDA disadvantages.

Answer 15

1. Good visualisation of abomasum.
   Can break down adhesions.
   Low recurrence.
   Animal standing.
   Useful in cows in late gestation.
   - uncommon.
   Useful if had surgery on LHS already and scar tissue an issue.
2. Cost.
   Time.
   Poor abdomen visualisation.

Question 16

Right paramedian laparotomy and abomasopexy approach to LDA process.

Answer 16

Fairly common.
Cast cow into right lateral recumbency.
Roll into dorsal recumbency, so abomasum floats to caudal abdominal wall.
Make a paramedian incision a hands breadth to the right of midline and a hands breadth caudal to the xyphisternum.
Identify abomasum.
Form an abomasopexy - suture abomasal fundus to the internal layer of the rectus sheath and peritoneum.

Question 17

1. Right paramedian laparotomy and abomasopexy approach to LDA advantages.
2. Right paramedian laparotomy and abomasopexy approach to LDA disadvantages.

Answer 17

1. Allows visualisation of abomasal fundus and some other abdominal viscera.
   Adhesions with left body wall can be managed.
   More rapid than other closed procedures.
   Surgeon arm length not restrictive.
   Low risk of recurrence.
   Appropriate for any size of displacement.
2. Requires cow to be rolled.
   Cost.
   Time.
   Poor abdomen visualisation.

Question 18

Closed approach toggle pin suture approach to LDA process.

Answer 18

Common.
Use of a toggling kit.
Similar to casting and rolling.
Cast cow into right lateral recumbency and then rolled onto back.
- abomasum floats up to ventral body wall of cow.
- locate abomasum with ping. If absent. Abort procedure and continue the roll.
- if located, apply pressure to caudal abdomen to push abomasum cranially and ventrally.
- place trocar into abomasum, hands breadth to right of midline and hands breadth caudal to xiphisternum — must be performed quickly to be successful.
Push through toggling pin and suture line to pexy abomasum to ventral body wall.
- location confirmed by acidic smell of abomasal gas.
- first toggle quickly inserted using cannula and trocar removed before abomasum decompressed fully.
Grasp free end of suture securely with haemostats.
Re-insert trocar approx. 5cm cranial to the first toggle suture.
Second toggle suture put in place.
Gas can be allowed to escape through trocar.
Needle can be removed once fully decompressed.
2 suture ems secured together by a surgeon’s knot, leaving approx. Hand width thickness between tightened suture and body wall.
Cow then rolled onto left side and finally allowed to stand.
Leave in place for 10-14 days and then cut the string, releasing the toggles into the digestive tract to be passed in faeces by the cow.

Question 19

1. Closed toggle pin approach to LDA advantages.
2. Closed toggle pin approach to LDA disadvantages.

Answer 19

1. Quick.
   Cheaper compared to open surgery.
2. Blind.
   Can’t visualise abdomen viscera.
   Potential risk of trauma to personnel and cow.
   Requires rolling (space and man power).
   *pick your cases well!
   - classical signs.
   - within 2-3 weeks of calving.
   - off-colour and dropped milk yield.
   - but otherwise well.

Question 20

1. Laparoscopic correction methods of LDA.
2. Advantages.
3. Disadvantages.

Answer 20

1. Two-step method:
   - place toggle sutures on displaced abomasum through keyhole incisions, followed by rolling and retrieving sutures through ventral incision.
   One-step method.
2. Minimally invasive.
   Visual control.
   Quick.
   Minimal antibiotics required.
3. Requires ability to use laparoscope.
   Expensive equipment.

Question 21

After care for all abomasal surgery.

Answer 21

NSAIDS.
Antibiotics for open surgery.
Oral fluid therapy - 40-60L isotonic fluid to ballast the rumen.
Treatment of concurrent medical conditions e.g. metritis or ketosis.
Calcium - sub-clinical hypocalcaemia common in cases of LDA.
Dietary management (high fibre, low starch).

Question 22

Complications associated with LDA surgeries.

Answer 22

Abomasitis and abomasal ulceration.
Motility disorders:
- abomasal and rumenal hypomotility / atony.
Infection - peritonitis and wound infections.
Pexy failures +/- re-displacement.
Risk of creating adhesions and intestinal incarceration with surgeries performed.

Question 23

1. What is RDA?
2. Treatment?
3. Problem with RDA?
4. Px for straight-forward RDA?

Answer 23

1. Right displaced abomasum.
2. Conservative treatment appropriate.
   - as for LDA.
   - no rolling!
   - analgesia +/- spasmolytics.
   - calcium.
   - oral fluid therapy.
   - treat concurrent conditions.
   - high fibre, low starch diet.
   - regular monitoring every 2-4hrs in case torsion and volvulus occurs.
   *metaclopramide is completely illegal in food-producing animals in UK.
   Surgical if indicated:
   - cow shows signs of hypovolaemic or endotoxic shock.
   - severe or increasing abdominal pain unresponsive to analgesia.
   - no response ti conservative management in 2-4 hours.
   *early surgical intervention essential.
3. Very unstable and can progress to dilation with volvulus and torsion.
4. Fair.

Question 24

Surgical correction of RDA / RVA.

Answer 24

Correct fluid / electrolyte imbalances.
- metabolic alkalosis, sever hypochloraemia, hypokalaemia, hyponatraemia.
- IV hypertonic saline followed by large volumes of isotonic saline.
Perform right paralumbar laparotomy.
- gas and fluid decompression.
- an anti-clockwise volvulus can be corrected by clockwise rotation of abomasum using left arm placed medially.
— not easy —> often requires a few attempts.
- pyloropexy of omentopexy (as LDA) carried out after correction.
- guarded Px if RVA. — frank and honest conversation to have with farmer.

Question 25

Indications for rumenotomy.

Answer 25

Traumatic reticulo-pericarditis. Ruminal FB (especially if linear). Ruminal tympany. - alternatively place ruminal trochar and cannula. Grain overload and acidosis. Poisoning.

Question 26

Conservative management of traumatic reticulo-pericarditis.

Answer 26

Broad-spectrum systemic antibiotics. NSAIDs. Oral fluid therapy. Magnets. *Generally poor response.

Question 27

1. Surgical treatment of traumatic reticulo-pericarditis. 2. Specific signs to look out for of a wire.

Answer 27

1. Timing is crucial. Left paralumbar fossa laparotomy. Exploration of cranioventral abdomen alongside rumen and reticulum. - adhesions palpable between the reticulum and the diaphragm. Perform rumenotomy. - secure rumen to body wall with stay suture / rumenotomy frame and sleeve / 2 x intra-medullary pins. Siphon off excessive fluid from rumen with wide bore plastic tubing. Rumenotomy incision. Manual exploration and remove FB. Rumen closure - 2 layers, continuous inverting suture pattern, #2 synthetic absorbable suture material. 2. Acute cranial abdominal pain. Fast, shallow respiration. Holding elbows out abducted. Arched back. Pain on palpation of cranial lower abdomen. May have pyrexia. Typically grunt with reticular contraction and no response to conservative management.

Question 28

Px for traumatic reticulo-pericarditis.

Answer 28

Usually poor response to medical treatment. Surgery often unrewarding. Timing of Sx key. - at moment of exit of FB from reticulum. - easier and more successful if performed early. Guarded if peritonitis generalised. Very poor if muffled heart sounds. - suggests pericarditis.

Question 29

Indications for exploratory laparotomy.

Answer 29

Severe/increasing abdominal pain unresponsive to analgesics. Unresponsive or deteriorating shock. Distended SI loops, tight mesenteric bands or palpable impaction on rectal exam. Chronic ruminal indigestion/tympany. Complete absence of faecal production. Caecal dilation and dislocation. To obtain Dx: - cases where other methods have been unsuccessful or impractical. - or biochemistry suggests ion sequestration.

Question 30

How are ex laps performed in the cow.

Answer 30

Right flank paralumbar laparotomy with cow in standing position. - greater visualisation of abdomen. - but left flank may be indicated if think need to progress to rumenotomy.

Question 31

Differential for umbilical masses.

Answer 31

Umbilical hernia. Omphalitis (“navel ill”). Umbilical abscess (SC or intra-abdominal). Umbilical remnant infection. A combination of the above.

Question 32

What is an umbilical hernia?

Answer 32

Failure of umbilical closure. - congenital predisposition e.g. heritable in Holsteins. - acquired due to concurrent infection or due to trauma (overzealous chewing of the umbilicus by the dam). - a combination of the above.

Question 33

Clinical signs of an umbilical hernia?

Answer 33

Ventral midline swelling. Extends caudally from the umbilicus (1cm to >30cm). Feels soft. Non-painful. Normally reducible. Typically BAR with no impact on appetite or growth rates.

Question 34

Content of an umbilical hernia in order of greatest occurrence to least occurrence.

Answer 34

Greater omentum. Abomasal fundus. Intestinal loops - rare, due to short mesenteric attachments and omental sling.

Question 35

1. Umbilical abscess aetiology. 2. Clinical signs of umbilical abscess.

Answer 35

1. Secondary to navel ill/omphilitis. - Walled-off infection persists within the umbilical stump. Can be SC or intra-abdominal. 2. Typically firm, hot and painful. +/- draining sinus tracts and purple t umbilical discharge. +/- pyrexia or systemic signs.

Question 36

1. Aetiology of umbilical remnant disorders. 2. Which umbilical remnant disorder is the most common?

Answer 36

1. Failure of elastic recoil / post party closure of element of the umbilical cord. Concurrent umbilical hernia. Concurrent umbilical infection. 2. Urachal abscess.

Question 37

1. Clinical signs of urachal abscess? 2. Persistent urachus clinical signs?

Answer 37

1. +/- purulent umbilical discharge. +/- pyrexia. Poor growth / ill-thrift. Poikilluria. Stranguria, pyuria and haematuria if cystitis. 2. Uncommon. Leaking urine from the umbilicus.

Question 38

1. Umbilical vein abscess (omphalo-phlebitis) clinical signs. 2. Omphalo-arteritis clinical signs.

Answer 38

1. Uncommon. +/- purulent umbilical discharge. +/- pyrexia. Poor growth / ill-thrift. Septicaemia and death. 2. Rare. +/- purulent umbilical discharge. +/- pyrexia. Poor growth / ill-thrift.

Question 39

Diagnostic approach to an umbilical mass.

Answer 39

Full history of the mass. - present since birth? - developed? - growth compared to other calves born around same time. Full CE. - of umbilical area. - check for other signs of navel infection e.g. concurrent joint ill. Digital palpation of umbilical mass - soft and reducible? - firm, hard, hot swollen? Deep abdominal palpation. - start from umbilical mass and work dorsally then cranially and caudally in turn. — to see where mass tracking in the abdomen. Ultrasound examination. - ascertain umbilical mass contents e.g. intestines, pus etc. - prognostic assessment.

Question 40

Main diagnostic considerations for umbilical masses?

Answer 40

Is the umbilical mass non-painful, soft and reducible? Is the mass firm, hot and painful. Is there a purulent umbilical discharge? Is the calf pyrexia or systemically unwell? Does deep abdominal palpation reveal a palpable intra-abdominal extension? Does ultrasound exam reveal presence of omentum or gastrointestinal tract? Does ultrasound exam reveal presence of hyperechoic (“starry sky”) pus? Does ultrasound confirm an intra-abdominal extension of the umbilical mass?

Question 41

General tx options for umbilical masses after they have been diagnosed?

Answer 41

Conservative. Drainage. Umbilical herniorrhaphy. En-bloc resection.

Question 42

Conservative treatment for umbilical masses.

Answer 42

Resolution of small hernias. Systemic ABX if infected navel-ill or small SC abscess. - E. coli, T. Pyogenses. - synulox (amoxicillin). - minimum 5 days. - plus NSAIDs. Px good for small hernias, and omphalitis, but extensive scarring and fibrosis can lead to recurrence. Px poor of complicated case with concurrent umbilical hernia, abscessation or umbilical remnant infection.

Question 43

When can you drain an umbilical mass and what is the prognosis?

Answer 43

Simple umbilical abscess only. Use pre-op U/S or FNA to confirm dx. Prognosis good if simple umbilical abscesses. Prognosis poor if complicated umbilical abscess with concurrent herniation or if infected umbilical remnants remain.

Question 44

Approach to draining an umbilical mass?

Answer 44

Restrain the calf standing or in lateral recumbency. Surgically prepare incision site. Make bold incision (approx. 5cm long) at most dependent point of the mass. Express all purulent material and flush out with dilute iodine solution and more flush. Give systemic ABX. Give NSAIDs.

Question 45

1. Indications for umbilical herniorrhaphy (repair). 2. Timing of umbilical herniorrhaphy? 3. Anaesthesia for umbilical herniorrhaphy?

Answer 45

1. Umbilical hernias greater than 3-5cm. Complicated umbilical hernia. 2. At around 3-4m old if poss. 3. GA preferred by author. Lumbosacral epidural and sedation.

Question 46

Umbilical herniorrhaphy approach.

Answer 46

Dorsal recumbency. Elliptical incision around hernia base. - ensure sufficient skin retained to allow closure. +/- lateral preputial reflection in male animals. Blunt dissect hernia ring to invert it into abdomen to free peritoneum into body wall, allowing inversion back into abdomen - need to fully remove skin from elliptical incision to allow this to happen. Invert hernial sac into abdomen. Debrief margins of hernial ring to improve adhesion. Use either mayo overlapping suture (vest over pants) or horizontal mattress sutures. Oversew abdominal wall margin in a simple continuous pattern. Routine closure of subcutaneous tissues and skin. Possibly secure stent over incision to provide protection for first 24-72hrs.

Question 47

What are meshes?

Answer 47

Rarely use in farm work. Designed to close large defects. Polypropylene or steel meshes. Must be placed under strict sterile surgical conditions. Contraindicated if: - on farm due to compromised asepsis. - complicated hernias with concurrent infection.

Question 48

1. Indications for en bloc resection of umbilical masses. 2. Pre-op considerations for en bloc resection of umbilical masses. 3. Anaesthesia?

Answer 48

1. Chronic, intractable omphalitis. Umbilical abscess complication by herniation. Umbilical remnant infection. 2. C&S. Systemic ABX. - min 3d pre-surgery. U/S abdomen. - tract infection within abdomen. 3. GA essential.

Question 49

Approach for en bloc resection of umbilical masses.

Answer 49

Initially as for umbilical repair. Extreme care to avoid rupturing abscesses. Tent abdominal wall and incise peritoneum either: - cranially — in cases or urachal abscessation and omphaloarteritis. - caudally — in cases of umbilical vein abscessation. Carefully respect mass from abdominal wall. And continues to respect along where abscess goes, with care! - urachal abscessation — proximal urachus ligated or bladder tip amputated. - umbilical vein abscessation — proximal umbilical vein ligated, or if extends into liver tissue, marsupialised at separate site! - umbilical artery abscessation — tract as far as poss into abdomen, ligate and remove close to aorta. Closure as for umbilical herniorrhaphy. Post-op care: - NSAIDs. - ABX, minimum 5-7d. - abdominal bandaging or stent. - keep animal confined to prevent excessive movement for 3-4 weeks.

Question 50

Post op complications for en bloc resection of umbilical masses.

Answer 50

Serosa formation (common). - generally 5-7d post op. - keep confined for 3-4w post op. - ensure doesn’t get infected. Unable to respect fully and infection left in abdomen. - care where umbilical vein tracking into liver. Peritonitis.

Question 51

Rectal prolapse in calves.

Answer 51

Uncommon. May be due to coccidiosis causing diarrhoea and straining causing prolapse. Use standing restraint. Caudal epidural anaesthesia. Simple replacement: - in simple, fresh mucosal prolapse. - retain rectum in normal position with purse string suture. — place suture 1-2cm outside anal sphincter. — anal opening should allow adequate faecal passage. — suture should remain for several days only. Rectal amputation: - insert a firm walled open tube into lumen of prolapse. — plastic tubing or syringe cases may be considered. - anchor with a circumferential ligament outside the anis at the most proximal position of the prolapse. - tube and ligature will stimulate sloughing of the distal position of the prolapse.

Question 52

What is atresia ani / coli / recti.

Answer 52

Congenital abscence of section of terminal GIT. Atresia ani: - lambs. - surgical recreation of opening. - vertical incision made over anal sphincter, the blind end of rectum dissected. - perirectal tissue sutured to dermis, blind end of rectum incised and rectal mucosa sutured to skin. - Px with surgical correction is good. Atresia coli and recti: - calves. - v poor Px even with surgical correction. - euthanasia should be considered.