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Intestinal Surgery Flashcards

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1
Q

What is one of the most common indications for laparotomies?

A

foreign body obstructions

  • DOGS = non-linear
  • CATS = linear
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2
Q

What is the holding layer of the intestines?

A

tunica submucosa

  • engage with all sutures to provide mechanical strength
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3
Q

What kind of suture is preferred for intestinal surgery? What can you do if you’re concerned about leakage? What should be done before abdominal closing?

A

small, monofilament synthetic absorbable or nonabsorbable swaged on taper needles

cover surgical site with omentum or serosal patch

lavage

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4
Q

What cleanliness level is associated with intestinal surgery? How can this be alleviated?

A

clean-contaminated or contaminated

  • replace contaminated instruments and gloves before closing abdomen
  • use prophylactic antibiotics
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5
Q

What prophylactic antibiotics are recommended for the different segments of the intestines?

A

UPPER AND MIDDLE SMALL INTESTINE - first-generation cephalosporins (cefazolin)

LOWER SMALL INTESTINE AND LARGE INTESTINES - second-generation cephalosporins (cefoxitin)

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6
Q

Why are multifilament sutures not recommended for intestinal surgery? How should tissues be handled?

A

causes more tissue drag and potentiates infection

handle gently and grasp as little as possible —> risks intestinal occlusion

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7
Q

What clinical signs are associated with intestinal foreign bodies?

A
  • vomiting
  • anorexia
  • depression
  • abdominal discomfort
  • diarrhea
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8
Q

What is seen on radiographs with intestinal foreign bodies? How is it confirmed?

A

multiple loops of gas-filled dilated intestines

compare ratio of small intestine diameter to the height of the cranial endplate of L2

  • <1.6 - no obstruction
  • > 3 - strongly associated with obstruction
  • > 4 - 95% confidence for obstruction
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9
Q

How are intestinal foreign bodies treated?

A

explore the entire abdomen for intestinal viability

  • healthy = enterotomy
  • necrotic = R/A
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10
Q

How is intestinal viability evaluated?

A
  • peristalsis on pinch test
  • color (purple = necrotic)
  • pulsation of vessels and motility
  • wall texture or thickness (thin = nonviable)
  • fluorescein infusion
  • surface oximetry
  • bleeding of sero-muscularis when incised
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11
Q

What are the 3 indications for enterotomies?

A
  1. removal of intraluminal foreign bodies
  2. full-thickness biopsy samples
  3. evaluation of intestinal mucosa to determine viability
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12
Q

What is the general surgical technique of enterotomies?

A
  • milk stool away and atrumatically occlude intestine (with Doyens) proximally and distally to prevent leakage
  • make a stab incision into the lumen and extend with scalpel or Metzenbaum scissors ABORAD to the foreign body

(if incision is too small, risk traumatizing the tissue with removal)

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13
Q

Where are intestinal foreign bodies most commonly found?

A

caudal duodenal flexure

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14
Q

How are enterotomies closed? What is avoided?

A

simple continuous or interrupted sutures 2-3 mm from the edges and each other to appose the mucosa accurately (AVOID EVERSION)

  • double layer —> makes lumen too stenotic
  • long tags
  • rough handling —> hematomas
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15
Q

How can the diameter of the intestinal lumen be increased in enterotomies?

A

close transversely by placing the suture at the center of the incision

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16
Q

How can eversion after suturing up an enterotomy be avoided?

A

thumb forceps can correct position and go under the submucosa to engage it

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17
Q

What is performed after suturing up an enterotomy or eneterectomy? What kind of test is this?

A

water test - saline injected into lamina to check for leak (leakage = more suture or omental patch)

SUBJECTIVE —> all anastomosis can be made to leak if enough pressure is applied

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18
Q

What are the 4 indications for enterectomies?

A
  1. removal of non-viable (necrotic or ischemic) instestine
  2. removal of irreducible intussusceptions
  3. removal of traumatized intestines
  4. removal of solitary neoplasms and fungal lesions
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19
Q

How is pulse oximetry and fluorescein dye used to detect intestinal viability?

A

normal saturation would be within 1 cm of normal peripheral O2 saturation

detects non-viable bowels

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20
Q

What is the standard technique for enterectomies?

A

end to end approximating pattern using simple interrupted or continuous suture

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21
Q

How are simple continuous sutures placed for enetercomies? What 3 advantages are there?

A

only 180 degrees —-> 360 not recommended

  1. technically easy
  2. maximizes luminal diameter
  3. results in rapid mucosal regeneration
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22
Q

What is the general surgical technique of enterectomies?

A
  • mesenteric vessels of the segments of the intestine to be remove are ligated
  • 2 clamps are placed on each side of the area of resection
  • intestine is transected with a scalpel or scissors

(debride fat, which makes it harder to close)

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23
Q

What clamps are used on enterectomies? How do the borders of the intestines compare?

A
  • atraumatic Doyens on conserved intestine
  • crushing clamps on the section to be removed

antimesenteric border is shorted than the mesenteric

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24
Q

How are the intestines cut on enterectomies to preserve the diameter? How is torsion avoided?

A

cut is angled

one suture on the mesenteric then antimesenteric borders for apposition, then the remaining suture are placed 3 mm from the edge of tissue and each other (keep tags long initially to manipulate intestines without touching)

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25
How is the rent on the mesentery sutured?
with very delicate sutures to avoid stricture in the future
26
How are anastomoses between sections of intestines with disparity in lumen size done?
- transect the small segment at an acute angle and a large segment at a more obtuse angle - space sutures in the large segment farther apart - incise the antimesenteric border of the smaller segment to spatulate (fish-mouth) the smaller segment
27
What are the 3 types of intestinal anastomosis? How are staples placed?
1 end to end 2. end to side 3. side to side place 3 stay sutures, then apply the staples ---> causes some eversion that can lead to further adhesions
28
How is the mesentery sutures following an enterectomy?
3-0 or 4-0 absorbable sutures in a simple continuous or interrupted pattern
29
What is an omental patch? Serosal patch?
the greater omentum is wrapped around a surgical site for support and to stimulate healing taking the antimesenteric border of a healthy, adjacent intestinal loop and suturing it over a defect for support
30
What are 2 indications for serosal patching?
1. questionable area of suturing after and eneterotomy or anastomosis with tension, damage to serosa, or dehiscence 2. superficial trauma to the intestinal wall
31
How is a serosal patch attached to the intestine? What should be avoided?
sutures engage the submucosa, but DO NOT penetrate the mucosa twisting, stretching, or kinking of the intestine or mesenteric vessels
32
What are 4 indications for serosal patching? When will mucosa span the defect?
1. when omentum is not available 2. closure integrity is questionable 3. non-resectable duodenal defects 4. enterotomy, colotomy, urinary bladder within 8 weeks
33
What kind of anastomosis do staplers provide?
side to side, functional end to end (GIA and TA staplers)
34
What is an enteroenteropexy? How is it performed?
intestinal plication developed to prevent recurrence of intussusception small intestine is placed in gentle loops and seromuscular/submucosal layers are sutured with small simple interrupted sutures
35
What kind of incision is preferred for enterotmoies? Where is it placed?
longitudinal on the antimesenteric border ABORAD (distal) to the obstruction
36
How are enterotomies closed?
longitudinally with 4-0 monofilament in a simple continuous or interrupted pattern - sutures 2-3 mm from edge and apart
37
What is the point of omentalizing?
- angiogenic - immunogenic - adhesive - controls infection - lymph drainage
38
How does the use of scissors and scalpels compare for cutting intestine?
SCISSORS = more control, more traumatic SCALPEL = less control, less traumatic
39
What kind of intestinal obstruction results in more severe signs?
- complete - high - strangulated
40
What are some clinical signs associated with intestinal obstruction?
- vomiting - dehydration - electrolyte imbalance, acid-base abnormalities - abdominal pain - distended loops of intestine on radiographs - palpable abdominal mass
41
How should patients be stabilized for intestinal obstructions?
- correct acid-base, fluid, and electrolyte abnormalities - IV antibiotics with first dose at induction and every 90 mins during procedure: cefazolin (stomach, proximal intestine) and cefoxitin (lower small intestine, colon) - treat shock
42
How should foreign bodies in the colon be corrected?
if they were able to pass into the colon, they usually pass in the feces - only remove surgically if there is concern for damage (sharp objects)
43
What are the 6 most common causes of intestinal obstruction?
1. foreign bodies - linear in cats, non-linear in dogs 2. intussusception - young dogs 3. mesenteric torsion - older GSD 4. ileus - post-op or post-obstruction 5. neoplasia 6. trauma
44
How sensitive if the GIT to hypoxia?
- superficial villus injury after 20 mins - destruction of villus after 60 mins - wall edema, bleeding, and mucosal sloughing within 1-3 hours - transmucosal necrosis after 4 hours - turgidity, transmural infarction, and whole blood accumulation within 8 hours - black, distended, and elongated appearance within 8-12 hours - gaseous bowel distention and loss of fluid into the lumen within 12-36 hours - gross necrosis within 20 hrs *death due to hypovolemia within 3-4 days*
45
What acid-base changes are expected with intestinal obstructions at different segments?
- pyloric/proximal duodenal = metabolic alkalosis - mid-duodenal/ileal = metabolic acidosis
46
What are 3 causes of fluid loss associated with intestinal obstruction?
1. vomiting 2. sequestration in intestinal lumen due to increased secretion and decreased absorption 3. edema of intestinal wall, especially with venous occlusion
47
What is strangulating obstruction? What 4 things does this result in?
simple obstruction leading to occlusion of blood supply to the intestine 1. bacterial overgrowth 2. increased bowel permeability 3. perforation and escape of bowel contents 4. peritonitis
48
What are 5 causes of strangulating obstructions?
1. strangulated hernia 2. some foreign body obstruction 3. intussusception 4. mesenteric torsion 5. adhesions/bands
49
What are the most common linear foreign bodies? How do they occur?
CATS ---> thread, nylon stocking, rope, string - anchors around the base of the tongue or pylorus - peristalsis carries FB down the GIT to form accordion-like pleats - FB embeds in mesenteric border and can perforate intestines
50
What are the most common clinical signs associated with linear foreign bodies?
- vomiting - anorexia - depression - abdominal palpation results in pain and clumping/pleating of intestine
51
What is avoided when removing linear foreign bodies?
pulling it out ---> don't know what is at the end or how far it has gone
52
What is observed on radiographs and contrast studies in patients with linear foreign bodies?
plicated intestines bunched in the cranial/central abdomen more obvious pleating with teardrop shaped air bubbles
53
Where are linear foreign bodies most commonly lodged in dogs?
at the pylorus ---> need surgery, 40% have peritonitis at the time of surgery
54
How are linear foreign bodies surgically managed?
- free FB cranially from the base of the tongue or by gastrotomy - examine the mesenteric border for perforations - remove the FB through enterotomy(ies)
55
How are linear foreign bodies surgically managed with a catheter?
- free FB cranially - make a 1 cm enterotomy in the antimesenteric border of the proximal duodenum - tie FB to the catheter and milk it doen the intestines - comes out of anus or separate enterotomy incision (aka Andersen technique)
56
How are mesenteric perforations treated in cases of foreign bodies?
- examine the mesenteric border with FB in place - repair the perforation (if there are multiple perforations or compromise to the blood supply, a R/A if recommended)
57
Linear foreign body:
accordian-like plication!
58
How do linear foreign bodies typically affect the intestine?
may lacerate the mesenteric border - R/A recommended if intestine is perforated
59
What is intussusception?
telescoping of one segment of intestine (intussusceptum) into an adjacent section (insussuscipiens) - intussuseptum is usually proximal, but reverse peristalsis can cause reverse telescoping
60
In what animals is intussusception most common? What does this commonly result in?
puppies ---> associated with hypermotility, usually caused by diarrhea or parasites - venous occlusion - perforation - peritonitis - bloody diarrhea, vomiting, abdominal pain (often palpable)
61
What are the characteristic signs of intussusception on ultrasounds?
- dart board - side view = 4 layers of intestine
62
How are intussusceptions surgically treated?
gentle traction to take back intestine - if going well, monitor to recognize recurrence - check viability, necrotic intestines require R/A - irreducible = R/A
63
What is the most common signalment for mesenteric torsion?
- medium to large breed dogs, especially GSDs and Pointers - adult males
64
What are 9 predisposing factors to mesenteric torsion?
1. vigorous activity 2. dietary indiscretion 3. trauma 4. recent GI surgery 5. enteritis 6. parasitism 7. FB/obstruction 8. exocrine pancreatic deficiency 9. GDV
65
What are clinical signs of mesenteric torsion associated with? What are some examples?
partial obstruction and ischemia of the intestine - acute pain and shock - mild abdominal enlargement - depression, recumbency - nausea, retching, vomiting - hematochezia
66
What surgical treatment is recommended for mesenteric torsion?
- untwist and reposition intestine - allow for perfusion and evaluate tissue viability - resect devitalized tissue - lavage abdomen, drain the peritoneum (must be done within 60 mins, euthanasia is commonly treatment)
67
How much of the intestine is able to be resected? What happens if more is taken?
60-70% short bowel syndrome - not enough bowel to absorb nutrients, resulting in weight loss, diarrhea, malnutrition, anemia (folic acid def.) ---> requires special diet for life and supportive therapy until remaining intestine adapts
68
Why must mesenteric torsion treatment be done especially quickly?
- mortality approaches 100% - in most cases, entire jejunum and ileum are non-viable at the time of surgery - reperfusion injury can be lethal - short bowel syndrome
69
What post-op care is recommended for intestinal surgery?
- offer water or nasogastric tube trickle 6-8 hours after surgery - if no vomiting occurs, offer bland food 12-24 hours after surgery - reintroduce normal diet gradually at 48 hours after surgery - no antibiotics unless peritonitis is present
70
What are the 4 most common causes of peritonitis and dehiscence following intestinal surgery? What does this usually lead to?
1. poor suturing technique 2. non-viable bowel 3. use of chromic gut 4. delated healing (Cushings) SEPTIC PERITONITIS ---> occurs between 3rd and 5th day following surgery
71
What are the 2 options for peritoneal drainage to avoid peritonitis?
1. open abdominal drainage with highly absorbent padding over opening 2. close abdominal drainage with a Jackson Pratt for active drainage
72
Where in the GIT is neoplasia most common in dogs and cats?
DOGS = colon and rectum CATS = small intestine (most are malignant and highly metastatic)
73
What intestinal neoplasias are most common in dogs and cats?
DOGS = adenocarcinoma (M, intestinal), adenomatous polyp (B, rectal) CATS = lymphosarcoma (M, intestinal)
74
What is the most common signalment for intestinal adenocardinoma?
- dogs = 9 years; cats = 10 years - dogs = males, cats = females Boxers, Collies, GSD, Siamese cats
75
How do the clinical signs differ with small and large intestinal neoplasias?
SMALL = weight loss, anorexia, depression, diarrhea, vomiting LARGE = tenesmus, hematochezia, dyschezia, weight loss (more straining!)
76
What is most commonly seen on physical examination in intestinal neoplasia?
- palpable abdominal or rectal mass - dilated loops of intestine (obstruction) - anemia: leiomyosarcoma bleeding into intestine - peritonitis: perforation, necrosis
77
What is seen on radiography and ultrasonography with intestinal neoplasia?
RADIOGRAPHY - abdominal mass, dilated intestinal loops, intramural or annular lesions, diffuse filling defects in bowel wall US - enlarged lymph nodes, hepatic masses
78
When is intestinal R/A recommended for neoplasia? When is chemotherapy recommended?
- single mass - can resect < 70% of small intestine - no metastatic lesions present lymphosarcoma has some success (adenocarcinoma has poor results)
79
How is the treatment of malignant and benign neoplasia different? Prognosis?
- MALIGNANT: resection with 4-8 cm borders, only resect lymphosarcoma is obstructing - BENIGN: resection with minimal borders ADENOCARCINOMA: dogs = 10 months; cats = 2 years LEIOMYOSARCOMA: 12 months
80
How are surgical intestinal biopsies performed? What techniques are used?
full-thickness biopsy wide enough that all layers remain intact (3-4 mm wide) ---> most invasive, most diagnostic - longitudinal biopsy with longitudinal* or transverse closure - transverse biopsy - dermal punch
81
How are transverse wedge biopsies performed?
full-thickness wedge 3-4 mm wide taken perpendicular to long axis of intestine (should not be > 20-25% of circumference)
82
What are 4 characteristics of flexible endoscopy for biopsying the intestine?
1. least invasive 2. able to visualize mucosa 3. jejunum out of reach 4. no muscular layer
83
What are 3 characteristics of laparoscopic-assisted biopsies?
1. can biopsy jejunum and other organs 2. full thickness 3. cannot visualize mucosal lesions
84
How are antibiotics used in intestinal surgery?
- PROXIMAL SMALL INTESTINE = 1st gen, cefazolin - DISTAL SMALL INTESTINE = 2nd gen, cefoxitin - if used, should be in tissues by the time of surgery - continue no more than 24 hours post-surgery unless there is an ongoing infection
85
Why must pain management be done carefully after intestinal surgery?
opioids can cause ileus ---> preemptive Cisapride
86
What should be monitored following intestinal surgery? Why?
- general attitude - mucous membranes - abdominal palpation (pain can be because of sx!) - temperature - CBC - abdominocentesis of DPL - ultrasonography most complications occur in the first 3-5 days
Small Animal Surgery
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