Veterinary Surgery Preparation Quiz

Course Information

• Course: CVM 737-A, Introduction to Surgery
• Topic: Exploratory Celiotomy
• Date: January 23, 2025
• Instructor: R. Randall Thompson, DVM, MSpVM (SA Surgery)
• Affiliation: Liaison, DeBusk Veterinary Teaching Center, Associate Professor of Small Animal Surgery
• Institution: Lincoln Memorial University College of Veterinary Medicine

Learning Objectives

• Explain the anatomic structures involved and the method used to retract intestines to access the left and right "gutters" during an exploratory celiotomy.
• Describe the surgical approach to the abdominal cavity for performing an exploratory celiotomy on both male and female canine patients.
• Identify the appropriate minimum observation time for trauma patients and the reason for this time.
• Evaluate a case and recommend the appropriate use of prophylactic antibiotics intraoperatively.
• Given a clinical case presentation, identify the appropriate fluid for use in intraoperative lavage of the abdominal cavity.
• State the critical time period during which a surgical wound is most likely to dehisce, and the factors that increase the risk of wound dehiscence.
• State when a sponge count should be performed.
• Identify failure to complete the entire exploratory procedure as a significant cause of complications and overall failure in achieving successful outcomes.

Definitions

• Celiotomy: Incision into the abdominal cavity.
• Laparotomy: Flank incision (note: "midline laparotomy" doesn't exist).
• Acute Abdomen: Sudden onset of signs (distention, pain, vomiting) related to the abdomen.
• Abdominal Evisceration: Herniation of peritoneal contents through the body wall with exposure of abdominal viscera (e.g., appendicitis).

Reasons for Abdominal Exploratory Surgery

• Diagnostic biopsies
• Visualization
• Therapeutic procedures (e.g., gastric dilatation, volvulus, severe hemorrhage, colonic perforation, foreign body removal, evisceration).

Postoperative Major Abdominal Evisceration in a Recent Study

• Ovariohysterectomy (OHE) is the most frequent abdominal procedure in small animals and is the most likely cause of postoperative abdominal evisceration according to a recent study (Gower et al, JAVMA 234:1566, 2009).

Sage Advice

• Avoid unnecessary surgery.
• Only undertake surgery if the patient is likely to benefit.
• Finding a surgeon who is bold (courageous) yet clever (smart) and capable to perform and safely conclude surgical procedures is ideal.

Free Advice (Worth Everything)

• List samples, diagnostic procedures, prioritize and discuss the list with the primary clinician before proceeding with surgery.
• Take the list to the operating room (OR) and utilize it.

Preoperative Management

• Acquire detailed patient history.
• Perform a thorough physical examination.
• Conduct necessary radiographic studies.
• Perform necessary ultrasound studies.
• Carry out laboratory tests to gather necessary findings.

Physical Exam Findings - Beware

• Depressed/lethargic animals may not exhibit pain.
• Hemorrhage may not present for 3-4 hours following trauma (e.g., splenic or liver lacerations); thus, monitor trauma patients for 8-12 hours or longer.
• Mesenteric avulsion or ruptured biliary tract may not be apparent for 1-2 weeks

General Observations

• Observe the patient's attitude and posture.
• Measure the patient's temperature.
• Assess respiratory rate and effort.
• Evaluate heart rate and rhythm.
• Examine the abdomen (auscultation, percussion, and palpation).
• Conduct serial physical examinations.

Further Preoperative Management

• Place an intravenous catheter.
• Collect blood samples (hematocrit, total protein, glucose, blood urea nitrogen, complete blood count, and other tests as needed).
• Collect urine.
• Perform cystocentesis.
• Perform ultrasound-guided, palpation-guided, and blind stick procedures as needed.
• Catheterize the patient if required to record urine output.
• Establish an indwelling catheter to record urine output.
• Perform radiographs to identify any peritoneal fluid (blood, urine, or peritonitis), accumulation of air, etc.
• If radiographs are nondiagnostic, perform diagnostic peritoneal lavage (DPL) and perform FAST exams, focused assessments with sonography in trauma.
• Correct any electrolyte imbalances and hydration issues prior to surgery, whenever possible.

Critical Owner Communication

• Inform owners about the risk of post-operative infection and potential wound dehiscence.
• Inform owners that not all anomalies might be found during surgery.
• Let owners know that there's a possibility the pet might not survive surgery.
• Inform owners that more significant issues might not be immediately apparent but might emerge during surgery.

Anesthetic Considerations

• Consider the underlying disease and the animal's age to inform the anesthesia considerations for the procedure.
• The animal's current condition should be evaluated.
• The length and type of surgical procedure must be considered.
• Pain management must be considered.

Antibiotic Considerations

• Pre-operative patient history and overall health need to be evaluated to assess whether prophylactic antibiotics are warranted.
• Consider the length of the surgery (≤ 1.5 hours) and the presence of contamination of hollow viscera.
• Account for the surgical setting (OR vs. field conditions).

Surgical Instruments Needed

• Suction devices (e.g., Poole or Yankauer tips).
• Retractors (e.g., Balfour, malleable).
• Surgical instruments (e.g., right-angle forceps).
• Laparotomy pads (with markers).
• Saline solution in copious amounts.
• Necessary biopsy instruments.
• Culture and sensitivity equipment.
• Drains.

Surgical Anatomy

• Key anatomical structures (e.g., rectus sheath, external/internal abdominal oblique muscles, transversalis fascia, transversalis abdominus muscle, peritoneum) related to the surgical procedures.
• Differences between cranial and caudal anatomy.
• Important to understand relative location of structures, even if one cannot readily recall the names of structures.

Surgical Anatomy for Normal Veterinarians

• Understanding the linea alba (white line) in the abdominal region.
• How to locate the linea alba.

Canine Linea Alba

• Location of the linea alba in relation to the rectus sheath and other structures and it's variation in different anatomical locations, particularly relating to the xyphoid and pelvis.

Surgical Technique for Ventral Midline Incisions

• Extend the incisions (from xyphoid to pubis) to allow exploration of all abdominal organs.
• Ensure a proper surgical preparation of the canine patients (preparation for surgery).
• Count sponges before incision and before closing the surgical site. Do not use kick buckets.

Tips on "Prepping"

• Perform meticulous prepping with nice, even margins.
• Prevent razor burn and avoid injuries, e.g., to the nipples.

Tips on Wound Closure

• Carefully close the surgical wound with edges well-apposed and neatly spaced sutures.
• Avoid thumb forceps bruises on the surgical site.

Additional Observations

• Veterinarians who have never been off midline (e.g., during surgery) have likely never done surgical procedures.
• Addressing potential complications and surgical procedures can be done during the operation.
• Understand the implications for veterinary surgical techniques for appropriate and appropriate preparation of patient, instruments, and staff, leading to desired outcomes.
• Essential to have a methodical approach to surgical procedures.

Complications of Surgery

• Dehiscence (wound separation): most likely to occur 3-5 days post-operatively.
• Suture breakage.
• Knot slippage.
• Pull-through.
• Factors increasing dehiscence risk (wound separation): wound infection, fluid/electrolyte imbalances, anemia, hypoproteinemia, metabolic diseases, immunosuppression, corticosteroids, abdominal distension, patients with undergoing or having undergone chemotherapy, radiation therapy, and improper surgical procedures.
• Factors that delay surgical healing: debilition, very young, or age-related conditions such as very old age.

Lavaging the Abdominal Cavity

• Use warm lavage fluids to avoid hypothermia and reduce the risk of post-operative infections.
• Adding antiseptics to lavage fluids may not offer any benefits. It may even be harmful, especially for povidone-iodine used with peritonitis because it inhibits beneficial functions in macrophages.
• There is no evidence to support the benefits of adding antibiotics to lavage fluids.

Pre-Closing Checklist

• Inspecting the abdominal cavity for any presence of foreign substances or surgical materials.
• Confirming the complete and accurate accounting for all surgical instruments (sponge count).

Abdominal Wall Closure

• Closing the abdominal wall using a systematic approach: linea alba, subcutaneous tissue, subcuticular tissues, and skin closure.

Linea Alba Closure Technique

• Simple continuous sutures, but these do not increase the risk of dehiscence. Use strong absorbable sutures; and tie secure knots (6-8 knots per end).
• Interrupted closure techniques can be used as well.

Dos and Don'ts during Closure

• Dos: (1) Ensure a good apposition of tissue layers, (2) appropriate bites in the midline, (3) use external rectus sheath whenever appropriate, (4) utilize simple continuous patterns of sutures in subcutaneous layers, (5) consider re-approximating muscle fibers (especially useful in male canine patients), and (6) use appropriate sutures for skin closure (nonabsorbable).
• Don'ts: (1) do not strangulate tissues with sutures, (2) do not damage tissues with forceps, (3) do not incorporate the falciform ligament, (4) do not include any muscles during external sheath closure, and (5) do not attempt to approximate the peritoneum during abdominal wall closure.

Surgical Technique Considerations

• Methodical approach is important (e.g., use of systematic exploration technique).
• Don't deviate from the technique until the job is entirely done. Do not stop just because a significant issue was found. Always consider that additional issues might be present.
• Use of appropriate instruments.

Specific Procedure Steps

• Explore cranial quadrant, caudal quadrant, intestinal tract, and the gutters.

Cranial Quadrant Exploration

• Examine the diaphragm and esophageal hiatus using palpation.
• Visually inspect the entire liver.
• Assess gall bladder and biliary tree followed by expression if needed.
• Examine the stomach, pylorus, proximal duodenum, and spleen.
• Evaluate pancreatic limbs, the portal vein, hepatic arteries, and caudal vena cava.

Caudal Quadrant Exploration

• Evaluate descending colon.
• Evaluate the urinary bladder.
• Evaluate urethra.
• Examine uterine horns (or prostate, if present).
• Evaluate inguinal rings.

Intestinal Tract Exploration

• Palpate and visually inspect the duodenum to the descending colon.
• Observe the mesenteric vasculature and nodes associated with the tissues identified.
• Ensure that entire length of the intestinal tract is carefully evaluated.

Gutters Exploration

• Use the mesoduodenum to retract intestines for right gutter evaluation.
• Evaluate the right kidney, adrenal gland, ureter, and ovary (or stump) in the right gutter.
• In the left gutter, use the descending colon to retract intestines.
• Evaluate the left kidney, adrenal gland, ureter, and ovary (or stump).

Checklist Before Closing

• Confirm a complete exploratory examination.
• Review the prioritized list.
• Reappraise the biopsy sites.
• Complete any required lavage of the abdominal parts.
• Confirm absence of significant infection.
• Determine whether there is any sign of diffuse intraoperative contamination.
• Remove any lavage fluids used.

Additional Considerations

• Appropriate surgical techniques are essential to obtain good quality results.
• Note any required modifications to the standard surgical procedure.
• Account for specific patient needs.
• Communicate any important findings to owners.