1
Q
Primary reason for doing an Exploratory Celiotomy Biopsy?
A
Most efficient path (DX tool) to a definitive DX
2
Q
Causes for Exploratory Celiotomy
A
- Trauma → open to eval. internal damage
- Neoplasia → locate silent tumor
3
Q
When do you perform an Exploratory Celiotomy?
A
- Timing depends on history & PE
- Critical w/ trauma P
- DPL (Diagnostic Peritoneal Lavage) reduced uncertainty
- higher accuracy than abdominocentesis
- P is not responding
- Need stable P for successful surgery → sometimes stabilization cannot be reached → OPTIMIZE P
4
Q
How do you prep for an Exploratory Celiotomy?
A
- Wide clip
- Scrub SX site
- KY jelly →protects area from being soiled w/ fur
- Line incision w/ moist lap sponges →helps w/ sterility
- Towel drapes, then overdrape
5
Q
How do you position your P for an exploratory celiotomy?
(4 options)
A
- **Trendelemburg → caudal abdomen exploration **
- Reverse Trendelemburg → cranial abdomen exploration
- Horizontal table → thorough exploration of entire abdomen
- Dorsal recumbency = most common
6
Q
What approach do you take when performing an exploratory celiotomy?
(multiple options)
A
- Ventral midline = most common
- From xiphoid to pubis
- NO “keyhole” incisions!!!!
- Paracostal + ventral midline incision
7
Q
Equipment needed for an exploratory celiotomy?
A
- Balfour or Gosset Retractors
- Gelpi Retractors
- Lap Sponges
- Suction
- Doyen Intestinal Foreps
- Electroscapel
- Delicate thumb forceps - less traumatic than Adson-Brown or Rat thooth forceps
8
Q
Surgical Techniques for Exploratory Celiotomy
A
- Obtaind samples of free fluid after entering the peritoneal cavity
- Ignore obvious lesions unless life threatening
- Perform a thorough exploration
- Evaluation of size, shape, color, location, surface
- _Begin cranially w/ diaphragm _
- “Four quadrants” → cranial, caudal, left, right
- Always use the same technique
- **Utilize “anatomical” retractors **
9
Q
Biopsy Techniques during an Exploratory Celiotomy
A
- CLEAN tissues first!
- tissues w/ the LEAST potential for contamination (ex. biopsy of small nodule)
- Dirty tissues last!
- tissues w/ greater potential for contamination (ex. draining abscess)
10
Q
How does a P get chemical peritonitis?
A
From ruptured gallbladder
11
Q
Term for excising tissue w/ minimal safety margin?
(send whole piece to Path)
A
Excisional Biopsy
12
Q
What is the removal “protocol” for an excisional biopsy?
A
- Mark edges w/ sharpie or stitches
- Be careful w/ depth of biopsy
- don’t leave diseased tissue →may recur
- need 360 safety margin
13
Q
Term for taking a V shape or little piece of tissue & send to pathologist
A
Incisional Biopsy
14
Q
Why would you do an incisional biopsy over an excisional biopsy?
A
If you cant remove the entire mass b/c it is too big, but need to obtain a sample
15
Q
5 organs that are commonly biopsied
A
- Liver
- Intestines
- Lymph nodes
- Kidneys
- Prostate
16
Q
Why is the liver commonly biopsied?
A
- due to liver failure
- common site for metastasis
17
Q
What are the biopsy techniques used on the liver?
A
- Finger crushing
- Ligature Fracture Technique (Guillotine)
- Instrument fragmentation
- Wedge resection
- Biopsy punch
- Tru-cut
18
Q
How is the Finger crushing biosy technique done on the liver?
A
- One of the easiest techniques
- Best w/ dry sponge
- Squeeze w/ fingers
- **Double ligate any vessels **
19
Q
How is the Ligature fracture technique performed on the liver?
A
- Pass suture around piece of liver and tie strongly → makes knot → ligate vessels
- Leave 0.5 - 1 cm from ligature when cutting
- Can place pre-cut sutures & tie them → if tied too tight, it will create another biopsy → just cut section out
20
Q
Disadvantages of the Ligature Fracture Technique
(Guillotine Biopsy)
A
- Can only sample the margin of the hepatic lobe
- Requires a SX assistant
21
Q
How do you achieve hemostasis with a liver biopsy?
A
- Surgically
- Vetspon
- Omentum
22
Q
After finishing your liver biopsy and before you close, what should you check for?
A
Make sure there is NO biliary leakage!
23
Q
When taken a liver biopsy, do NOT excede ____ of intestinal _____
A
**Do NOT excede 20% of intestinal circumference **
24
Q
What suture pattern(s) do you use to close the intestines?
A
- Single layer closure
- NO INVERTING SUTURE PATTERNS!!! (Lambert, Cushing, Connell)
25
Technique for taking an intestinal biopsy
* Clamp w/ Doyen → milk contents to the side →make parallel incision → take sample w/ scissors
* **Finger clamp is less traumatic**
* Obtain **multiple full thickness samples** along length of intestine (~ 1 cm long)
* Preserve luminal diameter
* if significantly reduced after biopsy→ make dog ear suture (dilates bowel)
* Water leak test (inject saline into clamped intestines)- may need to place another stitch & recheck
26
What tissue/organ can you biopsy to determine if there is extension to dz?
Lymph Nodes
27
What is the easiest methods to biopsy a lymph node
FNA
28
What is the preferred biopsy method for Lymph Nodes?
Excisional BX
29
What is the advantage of an excisional lymph node biopsy?
Provides morphologic information
30
When perfoming a biopsy on the kidney, how to you acheive hemostasis?
Digital pressure
31
What suture pattern do you use to close after taking a biopsy of the kidney?
Use a mattress or continuous suture pattern
32
What type of biopsy is usually done on the prostate?
FNA or Wedge Biopsy
33
When performing a biopsy on the prostate, what do you need to watch out for?
What do you need to avoid?
* Watch out for bleeders
* **Avoid:**
* **penetrating urethra **
* **dosal aspect (trigone of the bladder)**
34
Organs that are less commonly biopsied
| (5)
* Stomach
* Spleen
* Pancreas
* Urinary Bladder
* Greater Omentum
35
What is the disadvantage of using an endoscope to biopsy the stomach?
Can't get full thickness BX
36
What procedure(s) do you use to perform a biopsy on the spleen?
Partial Spleenectomy
Wedge Resection
37
How do you perform a biopsy on the pancreas?
Partial Pancreatectomy - distal aspect
38
What should you do when removing an lymph node?
* Preserve regional blood supply
* Minimal handling
* Ligate blood supply
39
How do you perform an FNA of the kidney?
* Caudal → cranial direction
* Parallel to the cortex
40
How should you perfom a BX of the Urinary Bladder?
* Full thickness sample
* Inverting suture pattern
* (Lambert, Cushing, or Connell)
41
Where should you BX the Greater Omentum?
The distal aspect
42
Why should you ALWAYS perfrom an Abdominal Lavage before closing a contaminated abdomen?
* Removal of contaminants
* less chance of complications from foreign material in the abdomen
* Warms P
* shortens recovery time
* Increases survival & significantly reduces abscess formatino
43
What should you use for an Abdominal Lavage?
warm Isotonic fluid + heparin
| (repeat until clear fluid is retrieved)
44
When do you NOT perfom abdominal closure?
when peritoneal drainage is provided
| (??)
45
What is the technique for closing the abdomen?
* Use cruciate or simple interuppted pattern
* remove sutures after 7-10 d.
* **ONLY incoporate the External Abdominal Fasica**
* **Avoid the rectus abdominus mm. → incr. adhesions & complicates healing**
* **Internal sheath does NOT yield additional strength**
* Avoid dead space → risks of seromas
46
What is this positioning technique called?
Trendelenburg
47
What is this positioning technique called?
Reverse Trendelenburg
48
Name the 5 structures that are located in **BOTH CRANIAL** Quadrants of the abdomen.
(likely won't ask)
* Body of the stomach
* Transverse colon
* L limb of the pancreas
* Liver
* Diaphragm
49
Name the 8 structures that are located in the **R CRANIAL Quadrant** of the abdomen.
(likely won't ask)
* Diaphragm
* Epiploic foramen
* Caudal lobe of Liver
* R lobe & body of pancreas
* Pylorus & pyloric antrum
* Descending duodenum
* R Adrenal gland
* Cranial lobe of R kidney
50
Name the 6 structures that are located in the **L CRANIAL Quadrant** of the abdomen.
(likely won't ask)
* Diaphragm
* L liver lobes
* Fundus & body of stomach
* Cranial pole of L kidney
* Spleen
* L limb of the pancreas
51
Name the 8 structures that are located in the **R CAUDAL Quadrant** of the abdomen.
(likely won't ask)
* Descending duodenum
* Cecum
* R uterine horn
* R ovary
* Caudal pole of R kidney
* R ductus deferens
* R vaginal ring
* R ureter
52
Name the 8 structures that are located in the **L CAUDAL Quadrant** of the abdomen.
(likely won't ask)
* Descending colon
* Caudal mesenteric artery
* Mesocolon
* L uterine horn
* L ovary
* L ductus deferens
* L vaginal ring
* L ureter
53
Name the 6 structures that are located in **BOTH CAUDAL quadrants** of the abdomen.
(Likely won't ask)
* Uterine body
* Bladder
* Prostate (if enlarged)
* Terminal branches of Aorta
* Caudal flexure of duodenum
* Ileum
