Exploratory Celiotomy: Surgical Procedure

Exploratory Celiotomy

• Celiotomy refers to an incision into the abdominal cavity
• Laparotomy refers to a flank incision
• Abdominal evisceration is the herniation of peritoneal contents through the body wall, with exposure of abdominal viscera, such as "dropping guts"

Anatomic Structures

• Rectus sheath, external abdominal oblique (linea alba/"white line" where initial cut is made) internal abdominal oblique transversalis fascia, transversalis abdominus and peritoneum

Falciform Ligament

• An embryonic remnant attaching the diaphragm to the umbilicus and the liver

Surgical Approach

• Incision from the xiphoid process to the pubis (LARGE) entering the abdomen through the linea alba
• The abdominal wall is tented, and the linea alba is sharply incised with a scalpel
• Electrocautery is used to break down one side of the falciform ligament

Male Pre-operative Procedure

• The prepuce is flushed with antiseptic solution before sterile preparation
• The tip of the prepuce and a towel clamp are draped away from the surgical field
• The incision is curved before the prepuce to allows creation of a lateral incision, for example in cryptorchid surgery

Abdominal Quadrants

• Cranial quadrants include the diaphragm, gallbladder (assessed for filling of biliary ducts), stomach, proximal duodenum, both pancreatic limbs (right-duodenum and left-spleen), portal vein, hepatic arteries, and caudal vena cava
• Caudal quadrants include the descending colon, urinary bladder, urethra, uterine horns/prostate, and inguinal rings
• The intestinal tract extends from the duodenum to the descending colon
• The right side uses the mesoduodenum to retract intestines, and contains the right kidney, adrenal gland, ureter, ovary, or stump
• The left side uses the descending colon to retract intestines and contains the left kidney, adrenal gland, ureter, ovary, or stump

Layer Closure

• Layers are closed in the following order linea alba, subcutaneous, subcuticular, and skin

Post-operative Care

• Trauma patients require observation for at least 8-12 hours, due to a risk of post-operative hemorrhage within the first 3-4 hours
• Prophylactic antibiotics are not necessary if the surgery is under 1.5 hours and does not involve opening a contaminated hollow viscus (GIT, abscess)
• Always use WARM lavage fluids during intra-operative lavage of the abdominal cavity

Additional Surgical Considerations

• There is no need to add antibiotics to the fluid, which provide no benefit
• The critical time period for wound dehiscence is 3-5 days post-op, indicating a potential wound dehiscence
• Wound dehiscence is increased with infection, electrolyte imbalances, anemia, metabolic disease, immunosuppression, and hypoproteinemia
• A simple continuous pattern with linea alba, using 6-8 throws at each end, is preferred
• Using less suture material reduces the potential for dehiscence
• Do not strangulate or damage tissues with forceps and avoid including muscle when suturing the external rectus sheath or peritoneum, and use absorbable suture in the skin
• Always COUNT sponges before incision and before closing

Large Animal Standing Surgery (LA ST)

• Horses can lose a percentage of blood volume (BV) during surgery
  • Less than 15% BV (or 8% BW) results in no clinical signs
  • 15-20% BV, clinical signs develop
  • If they lose more than 40% BV, this indicates a death risk
• Equine patients should be recumbent for better access to most structures
• Bovine patients are better standing for surgery

Laryngeal Hemiplasia

• Diagnosed via URT Endoscopy
• Move tube through quickly, as horses are sensitive at the rostral nostril
• Either pharyngotomy or laryngotomy standing in surgery
• Mucosa heals rapidly and potentially for mucosal webbing
• Complications include excessive swelling leading to potential airway blockage, damage to cranial nerves, and reopening the airway too large, leading to aspiration potential and SSI with clean-contaminated or contaminated surgery

GI Tract Procedure

• Diagnostics include rectal palpation, abdominal ultrasound and radiographs, NG tube to measure excess gastric reflex, which correlates to excess gas in the stomach or SI blockage, abdominocentesis to evaluate fluid surrounding the intestines, and bloodwork

Ventral Midline Approach

• The paramedian area is made on the right side
• In an Exploratory laparotomy
• Enterotomy is a clean-contaminated procedure, as the bowel is entered
• It is bad if ingesta enters the abdomen or ruptures the bowel
• Resection and anastomosis are performed with a Lambert suture pattern on intestines

Complications

• Serosa causes intra-abdominal adhesions (fibrinolysis), causing post-opt death, hemoabdomen, ileus (“backing up" into intestines), and endotoxemia (hyperresponse to LPS)
• Prevent this with strict asepsis, lubes, gentle tissue handling, prevent blood from entering abdomen, and NEVER use dry gauze in LA

Laparoscopy Considerations

• Patient must be have an empty colon
• The abdomen is insufflated with CO2, and a blind stab incision is needed to place a scope portal
• Uses include Cryptorchidectomy, Ovariectomy and Abdominal exploration
• Antibiotics are ONLY needed if there is contamination, as normally it is a minimally invasive procedure
• Complications include SQ emphysema (gas), retroperitoneal insufflation, bowel perforation, and hemorrhage

Bone

• Bone is composed of cells and an extracellular matrix
• The extracellular matrix is roughly 35% organic material and water, of which 90% is Type I collagen and 10% osteocalcin/osteonectin
• There is 65% inorganic components, which is mostly Hydroxyapatite
• Osteoblasts are "building" bone

Bone Fractures

• Direct primary healing involves osteonal reconstruction
• Contact healing occurs with smaller gaps (< 300 microns) using osteons/cutting cones, to cross fracture planes
• Gap healing occurs with gaps < 1mm, as osteoblasts deposit perpendicular lamellar bone within the gap, and cutting cones transverse the fracture plane
• Requires rigid fixation, adequate reduction (only with simple fractures), and sufficient blood supply
• Rigid stabilization with bone plate

Indirect Secondary Bone Healing

• Majority of fracture healing occurs
• Faster than direct bone healing
• Less rigid stabilization is used with pins/wires, nails, etc
• Four phases of the healing: inflammation from hematoma, proliferation with intramembranous bone formation with Soft callus, maturation/modeling with chondrogenesis, invasion of BVs into cartilaginous matrix bringing them to osteoblasts that deposit bone on cartilage scaffold for bone formation and endochondrial ossification with Hard callus, and finally Remodeling
• The strain in healing is a fracture gap length expressed as a percentage
• Increased strain = decreased ability for fracture to heal
• Tissues present include granulation tissue (100%) > cartilage (10%) > bone (2%)
• Fracture Nonunion requires surgery

Hypertrophic Fracture

• This is viable with lots of callus but lack of bridging fracture site
  • Causes an "Elephant foot" and is caused by lack of stabilization, and excess weight on affected leg

Oligotrophic Fracture

• Viable with NO callus
  • Fibrous tissue + BVs joins fracture ends which is caused by displaced fracture ends

Dystrophic Fracture

• Nonviable which fragments only heal to one main fragment and not the other caused by poor blood supply, instability, geriatric Ps with poor BS

Necrotic Fracture

• Nonviable where fragments with no BS cannot heal: "Sequestrum"
• Caused by poor BS, infection at fracture site so it MUST remove

Large Defect Fracture

• Caused by massive bone loss at site where bone bridging cannot take place (gap in bone)
• Must create graft to repair

Atrophic Fracture

• Created from 3 nonviable nonunions
• A VERY poor prognosis with no viable bone
• Uncommon

Bone Treatments

• Rigid stabilization with screws, plates, etc and Bone grafting to enhance BS
• Treat infection, gaps, health of animals

Bone Fracture Malunion

• Fracture heals in non-anatomic position
• Caused by untreated or improper fracture tx, premature weight bearing
• Cause angular limb deformities, shortening limbs, abnormal gait, and DJD

Fracture Delayed Union

• Fracture is not healing within the expected timeframe and will use a Potential for grafting

Bone Grafts

• Autogenuous refers to the same individual
• Allograft refers to different individuals but same species
• Xenograft refers to different individuals and different species

** O's of Bone Grafting **

• Osteogenesis is where few osteoblasts actually survive the transfer
• Osteoconduction allows the graft to act as a scaffold (structure that provides a framework for tissue growth) where new bone is laid down
• Osteoinduction allows the graft to induces cells (BMP) to promote growth
• Osteopromotion is where material (platelet-rich plasma) enhances the regeneration of bone
• Cancellous is a type of bone graft from trabecular bone where the ilial wing, proximal tibia & humerus, or distal femur is used
• Preferred to keep bone grafts in blood soaked sponges & lack air exposure

Orthopedics Terms

• "Ortho" mean correct or straight
• "Paidion" means child
• Means to straighten the child

Other Terms

• Apophyseal osteotomies are procedures to enhance surgical exposure of the joint
• Bridging plates are used to span a comminuted fracture
• Closed reduction aligns the fractured bone without surgical exposure
• Crepitation refers to the "grating feel” or “cracky” sound that is associated with manipulating a fractured bone or arthritic joint
• External coaptation uses casts or splints for fracture fixation
• External fixation refers to fracture fixation where pins penetrate the bone and skin, and are connected externally
• Green stick fracture refers to an incomplete fracture where a portion of the cortex is intact
• Indirect reduction describes process of restoring fragment and limb alignment by distracting major bone segments
• Internal fixation: fracture fixation using internal implants to secure bone
• Intramembranous bone formation produces mesenchymal cells for bone production
• Nonunion: REQUIRES surgical intervention b/c fracture in arrested repair process
• Normograde placement is where pin starts at one end of the bone and driven to the other end
• Open/direct reduction involves fracture repair performed after a surgical approach
• Osteotomies: procedures where bone is cut into two segments
• Procurvatum is a cranial bowing of the bone
• Valgus refers to distal limb angled laterally
• Varus refers to distal limb angled medially
• Always take at LEAST 2 VIEWS of POTENTIAL FRACTURE, it is very important in fracture repair

Fracture Classifications

1. Open or closed to environment
2. Degree of damage or displacement
3. Type of fracture
4. Reducible or nonreducible
   • Reducible includes communicated (multiple fracture lines) fracture: < two segments fracture lines
     • Nonreducible includes MULTIPLE small fragments
5. Fracture location

Velocity

Determines number of fragments and amount of damage to STs High velocity = comminuted fractures with high energy displaced onto them

Bone Fractures - Open

1. Grade I
   • Puncture created by bone penetrating to outside thats around - 1cm
2. Grade II
   • Variable sized wound from external trauma
3. Grade III

• Severe bone fragmentation w/ lots of ST damage and associated with High-velocity comminuted fractures

Physeal Fractures (SALTER harris)

• Type I: separated at physeal plate
• Type II: separated at physeal and metaphyseal plate
• Type III: separated at physeal and epiphyseal plate
• Type IV: through physeal, metaphyseal, and physeal
• Type V: CRUSH injury of physis
• Type VI: partial physeal closures post physeal damage

Fracture Assessment Score Factors

• General patient info
• Radiographs of affected AND contralateral limb
• Client info
• High (8-10) = successful healing with fewer complications
• Moderate (4-7)
• Low (1-3) = less-successful with more complications
• Mechanical, biologic, and clinical factors guides implant choices

Flexible Endoscope uses

• Access to more sites in viscous organs, but more expensive, and easier to damage
• Handle is held by operator
• An insertion tube is inserted into P
• Umbilical cords attach the scope to the light source and video processor
• Biopsy channel allows instrument placement through scope

Rigid Endoscope uses

• More durable, easier to learn, and allows for larger biopsies
• Only have access to certain viscous organs = esophagus, descending colon, larynx, nose & trachea
• Has a lens at the scope tip
• Obturator: placed through follow endoscope to assist with insertion of scope into organ
• Trocar obturators are with a sharp point to help penetrate through tissue

Visualization

• Triangulation is visualization of instruments through scope and is the most difficult aspect of arthroscopy
• Portals is the insertion through skin or natural orifice and allows an ex) scope to be inserted through camera or scope portal, tools inserted through instrument portal
• Laparoscopy describes the endoscopy of the peritoneal cavity in diagnostic and interventional situations and includes Minimally invasive sx = gastropexy, Jejunostomy tube placement, OHE, and cryptorchid removal
• Arthroscopy is the endoscopy of the joint and includes a removal of a fragment Also allows for treatment of Meniscus injury and or Tenotomy (biceps tendon)

Superior Visualization Tools

• SUPERIOR to rads b/c allows direct visualization of cartilage and ST structures, magnification, and biopsy of almost all structures in joint allowing for a direct accessment to the condition of cartilage surface
• Cruciate and meniscal disease/damage are VERY common, so you must treat and remove tear before stabilization
• Always be prepared to perform arthrotomy (Sx) if not able to remove all fragments
• Normally have to perform sx anyway ~ 30% of the time
• Inflow/ingress refers to fluid flowing into the joint
• Outflow/egress refers to fluid flowing out of the joint

Benefits of Endoscopy

• Eliminates need for invasive surgery ONLY if successful and need appropriate training

Diagnostic aid

• Gastroduodenoscopy: indicated if need gastric and intestinal biopsy for diagnosis of infiltrative and lymphatic disorders
• Esophagoscopy: indicated for identification and removal of FBs and dilation of strictures (pooling of gastric acid within the esophagus)
• Cystoscopy: indicated for diagnosis of ectopic ureters
• Injects collagen that increases constriction of ureter to tx incontinence
• Rhinoscopy: indicated for diagnosis and removal of FBs, masses, and aspergillomas

Key Actions

• Do NOT use heat (wash only)
• Advance scope only if can you see where you are going
• If cannot see (“red out") back scope out slightly or insufflate some air or fluid into lumen
• Do NOT advance if this happens
• Aim the scope towards the center of lumen and do not force

Causes of Severe Acute Lameness (Equine)

• Foot abscess
  • Easily treatable and includes Localized infection hoof pressure PUS from neutrophils reacting to bacteria
• Cellulitis refers to an infection of SQ tissue that involves edema
• Septic synovial structure
• Nerve

Limp Determinations

• Resting FRONT legs (normal to rest hind legs) as lame on affected leg
• If you can NOT determine the source of lameness treat as FRACTURE always
• Stabilize and ALWAYS Immobilize the joint ABOVE and BELOW the fracture
• Have a Robert Jones bandage, if you do not you will need stable splints, not too thick

Regional Immobilization

• Region 1 includes proximal (P1) and middle phalanx (P2) fx that function to raise heal, while P3 fx do NOT require splint as fx within hoof itself, which provides protection
• Region 2: metacarpal/metatarsal 3 with full Robert Jones bandage + splints
• Region 3A: tibia or radius fx with full Robert Jones bandage + splint
• Region 3B: loss of triceps function plus full Robert Jones bandage + caudal full length splint
• Region 4: humerus, scapula, femur, or pelvis fx associated with large hematoma/swelling
• Cast application, if not done correctly, can be the source of other complications - Applications, Weight spread evenly with a cast and DO NOT end cast middle Appling a shoe and a cast

Considerations for Analgesia and Care

• Give analgesia ONLY after fx stabilized to improve overall outcome of surgery and use Supportive care = antimicrobials only for open fractures and IV fluids
• Transportation is vital to hospital and use Gooseneck trailers more stables

AAEP Lameness Scale

• 0-5
• 3 = lameness at trot
• 4-5 = very obvious when you recognize a limp
• Never apply a nerve block when a fracture is likely Incomplete: Can possibly see bones on films as its an increased osteoclastic activity with eating up bone and the building of of new bone

Open Fractures Prognosis

• WORST prognosis due to bacteria entering fracture site, which can lead to increase levels bacteria in the blood
• Cast applications, if not done correctly, can be the source of other complications
  • If the shoe is not pulled, it can damage the cast through applications - Always apply pressure evenly with a cast and DO NOT end cast middle
• Cut of Cast based on Cast Dependant on age, conditions, and complications
  • Depending on Growing Animals and Adult Animals

Developmental Considerations

• More common with YOUNGER breeds and primarily caused by inflammatory factors
• Panosteitis has Self Treatment or NSADIS that is rare to reoccur and if it dose shows a high success rate
• HOD: common infection
  • The infection Affects long bones and the Large breeds are commonly affected
  • Unknown can only be cause by limited number of cases
  • Self Treatment. Most recover within 7-10 days

Retaine

• Breaking done. Cartilaginous core to and a large breed can affect the feed for support

Leff Calse

• Mainly occur unilateral 85/15
• Can be treated with or without
• If non-paitfull medical treatment work but if its collapte then it will be need to be removed due to the lack of support.

Learn about exploratory celiotomy, including surgical approaches and anatomical structures. Celiotomy involves incision into the abdominal cavity, while laparotomy refers to a flank incision. Understand how to perform the procedure and the importance of anatomical knowledge.