Laparotomy

Question 1

What are the 3 major indications for laparotomies/celiotomies?

Answer 1

1. investigation to establish/confirm diagnosis, determine extent of disease or establish a prognosis
2. surgical correction of disease
3. supportive or prophylactic procedures

Question 2

What are 4 major indications for emergent celiotomy?

Answer 2

1. uncontrollable hemorrhage or inability to stabilize patient
2. free air on radiographs indicative of a perforated bowel
3. penetrating abdominal injury
4. bacteria, plant material, bilirubin, or predominantly toxic neutrophils on cytology

Question 3

What approach is used for exploratory celiotomies? What is required for adequate exposure?

Answer 3

systematic inspection (visual and palpation) of all contents - top to bottom vs. organ systems

incision from xyphoid to umbilicus or pubis to optimize visualization

Question 4

How are patients prepared for exploratory celiotomies?

Answer 4

• clip wide and drape narrow to allow ability to extend incisions and maintain minimal cutaneous exposure
• 4 quarter draping
• dorsal recumbency
• aseptic scrubbing

Question 5

How do surgeons prepare for exploratory celiotomies?

Answer 5

• count (radiopaque) sponges, sharps, and instruments (repeat count if sponges are added)
• place the ground plate of cautery devices ahead of time, since it’s hard to do once draped without breaking sterility

Question 6

What is the most common surgical approach to laparotomies?

Answer 6

ventral midline

Question 7

What is the paramedian approach? What is the most common reason this is done? Why is it mostly avoided?

Answer 7

an incision parallel to and just off of midline

usually caused by a missed ventral midline incision

cuts into muscle

Question 8

What is the paracostal approach?

Answer 8

incision parallel to the last rib along the internal/external obliques and transversus

Question 9

What is the flank approach? Why is it avoided?

Answer 9

incision perpendicular to the ventral midline, can be used to spay cats

results in a blood incision

Question 10

What are 2 common combinations of surgical approaches to laparotomies? Why are they used?

Answer 10

1. ventral midline and paracostal - liver approach
2. ventral midline and median sternotomy - dogs with chronic diaphragmatic hernias with adhesion

Question 11

What combination approach to laparotomies are used in males?

Answer 11

ventral midline and parapreputial

Question 12

How does the linea alba of cats compare to dogs?

Answer 12

CATS = wider, more transparent

DOGS = may need to dissect away subcutaneous tissue to visualize it better

excessive dissection may result in dead space

Question 13

What is the general approach to opening up for an exploratory?

Answer 13

• ventral midline approach
• stab incision created at 45 degrees
• extended cranially if using a scalpel and groove director or caudally if using scissors
• palpation with finger after slightly opened with blunt dissection of adhesions
• xyphoid to umbilicus/pubis

Question 14

Where is the falciform ligament found? What is done to it in exploratory celiotomies?

Answer 14

starts at umbilicus and goes cranial to the end of the abdominal cavity

resected from umbilicus cranially if it is really big, since it can form adhesions

Question 15

What organs are found in the cranial abdomen?

Answer 15

• diaphragm
• esophageal hiatus
• liver
• gall bladder
• stomach
• left limb of the pancreas

Question 16

What organs are found in the central abdomen?

Answer 16

• ascending colon
• ileum
• jejunum
• mesenteric nodes

Question 17

What organs are found in the caudal abdomen?

Answer 17

• duodenocolic ligament
• urinary bladder
• uterine body
• prostate

Question 18

What organs are found in the right abdomen?

Answer 18

• duodenum
• right limb of the pancreas
• right adrenal gland
• right ureter
• right kidney
• right ovary and uterine horn

Question 19

What organs are found in the left abdomen?

Answer 19

• descending colon
• spleen
• left kidney
• left adrenal
• left ovary/uterine horn
• left ureter

Question 20

What must be done before closure of exploratory celiotomies?

Answer 20

• check biopsy sites for hemorrhage
• sponge count
• lavage with warm irrigation system

Question 21

What is the point of lavaging before closing exploratory celiotomies?

Answer 21

• dilutes contaminated surgery sites, perforated bowels, and peritonitis
• can warm hypothermic patients

(minimum 200-300 mL/kg

Question 22

How are exploratory celiotomies closed?

Answer 22

3 layer closure

1. external rectus fascia (holding layer) - simple interrupted or continuous
2. subcutaneous tissue - simple interrupted or continuous
3. skin - intradermal or external sutures

Question 23

What 2 types of suture are preferred for the external rectus sheath? What are the recommended suture sizes?

Answer 23

1. intermediate to long-lasting absorbable - PDS, PGS
2. nonabsorbable if delayed healing is expected - polypropylene, monofilament nylon

• < 5 kg = 3-0
• 5-10 kg = 2-0
• > 10 kg = 0

Question 24

How are bites spaced when closing the fascia?

Answer 24

at least 5 mm wide —> close enough to appose tissue with no gaps, should not be able to insert tips of hemostats between sutures

• do NOT incorporate muscle

Question 24

How is closing the external rectus sheath of paramedian incisions different? Why?

Answer 24

closure of the internal rectus sheath is NOT necessary - promotes adhesions - most potent trigger for hypoxia

Question 25

How can closure of the external rectus sheath be evaluated?

Answer 25

- lift on suture bites, whole body wall should move - place finger in incision line and lift up, trying to insert tips of hemostats between sutures (bites < 5 mm wide have half the strength of those > 5 mm wide)

Question 26

What is the most common pattern for closing subcutaneous tissue? Why? How can dead space be decreased?

Answer 26

simple continuous - has increased bursting strength and distributes force equally interrupted sutures with bites into underlying fascia (ensure vertical bites enter and exit close to the base of the dermic for best apposition)

Question 27

What is the intradermal suture pattern?

Answer 27

- continuous patter where bites are taken parallel to the wound edge at the base of the dermis - suture bites exit and enter directly across from each other or slightly overlap for tighter closure

Question 28

How do subcutaneous and intradermal compare?

Answer 28

SQ = better for animals with a lot of subcutaneous fat, bites taken perpendicular to skin edge INTRADERMAL = used for more accurate apposition, skin sutures may not be necessary, bites taken parallel to skin edge

Question 29

What is the point of burying the knot? In what 2 patterns is this done?

Answer 29

inverted knots reduce likelihood suture ends will become exposed 1. subcutaneous 2. intradermal

Question 30

How is burying the knot done?

Answer 30

- first bite = deep to superficial - second bite = superficial to deep

Question 31

How far apart are skin sutures placed? What is the general rule of thumb?

Answer 31

~ 5 mm wide ---> smaller suture = more inflammation skin edges will appose better and with fewer sutures when wide bites are used (only suture the skin!)

Question 32

What is the most common complication associated with laparotomies? What is the main cause?

Answer 32

evisceration weakness in body wall closure - NOT from patients pulling out skin sutures