Laparotomy Lecture 2022 PDF

By Prof. Dr. Ashraf Abu-Seida 2022 https://scholar.cu.edu.eg/?q=ashrafseida/ classes/laparotomy  Surgicalprocedure to open the abdominal wall for good exposure of the abdominal and/or pelvic organs.  Lapar = abdomen and otomy = incision or op...

By Prof. Dr. Ashraf Abu-Seida 2022 https://scholar.cu.edu.eg/?q=ashrafseida/ classes/laparotomy  Surgicalprocedure to open the abdominal wall for good exposure of the abdominal and/or pelvic organs.  Lapar = abdomen and otomy = incision or opening.  Laparotomy = Celiotomy  For exploration of the abdominal cavity to facilitate diagnosis (Open and See)  For drainage of abdominal cavity from ascitic fluid (in cases of hepatic, cardiac and renal dysfunctions), urine (in case of ruptured urinary bladder) and lavage (in case of perforated abdominal wound).  For any surgical interference in the internal organs such as: - Gastrointestinal tract (gastrotomy, enterotomy, rumenotomy, abomasopexy, intestinal resection and anastomosis). - Excision of any abdominal neoplasms. - Hepatic, splenic and pancreatic surgeries. -Urogenital tract (ovariectomy, ovarohysterectomy, caesarian section, cystotomy, nephrotomy, nephrectomy, prostatectomy and abdominal cryptorchidectomy).  For herniorrhaphy.  For experimental studies External Internal  The abdomen is divided into three regions by two planes; a line between the margins of last ribs and a line between the tuber coxae  These regions include: - Epigastric region (Cranial third). - Mesogastric region (Middle third). - Hypogastric region (Caudal third).  These main regions are subdivided by two sagittal planes; drawn from middle of inguinal ligaments and parallel to linea alba as follow:  Epigastric region: - Xiphoid area (Suitable for gastrotomy and splenectomy) - Left paracostal (hypochondric) area (Suitable for splenectomy) - Right paracostal (hypochondric) area (Suitable for hepatic surgeries)  Mesogastric region: - Umbilical area (Suitable for ovariectomy) - Left lumbar area (Suitable for surgeries of the left kidney) - Right lumbar area (Suitable for surgeries of the right kidney)  Hypogastric region: - Prepubic area (Suitable for cystotomy and hysterectomy in females) - Left inguinal (iliac) area (Suitable for cystotomy in males) - Right inguinal (iliac) area (Suitable for cystotomy in males)  Ventral midline laparotomy: In which, laparotomy is performed through linea alba. It is divided into: - Cranial midline laparotomy (as in gastrotomy) - Middle midline laparotomy(as in ovariectomy) - Caudal midline laparotomy (as in cystotomy in females)  Paramedian per-rectus laparotomy: In which, laparotomy is performed through rectus abdominis muscle. It is divided into: - Cranial paramedian per-rectus laparotomy (as in splenectomy) - Middle paramedian per-rectus laparotomy - Caudal paramedian per-rectus laparotomy (as in cystotomy in males)  Paramedian lateral-rectus laparotomy  Paracostal laparotomy  Ventral midline-paracostal laparotomy  Paralumbar-paracostal laparotomy (lazy S shape)  Inverted T laparotomy (Mercedes shape)  Anesthesia: Equine: Inhalation anesthesia OR Deep narcosis by chloral hydrate 5g/50kg, 10% solution, given I/V + Local linear infiltration of Lignocaine HCl (1mL/1cm). Ruminants: Xylazine HCl 2% at a dose of 0.1mg/kg + Local linear infiltration of Lignocaine HCl (1mL/1cm) Dogs and cats: General anesthesia by atropine sulphate (0.1mg/kg, S/C) + Xylazine HCl 2% (1mg/kg, IM or IV) + Ketamine HCl 5% (5-10mg/kg in dogs and 20- 33mg/kg in cats, IM or IV) + Thiopental sodium for maintenance in dogs (25mg/kg 2.5 %, IV). Control: Dorsal or lateral recumbency depending upon the laparotomy approach.  Pre-operative technique: - Fasting of the animal - Clipping and shaving of hair at the site of laparotomy. - Washing with water and soap - Dryness with sterile towel - Disinfection with Ethyl alcohol - Painting with Povidone iodine - Draping with sterile towels.  Surgical technique: - Skin incision - Blunt dissection of s/c tissues. - Raising of the abdominal muscles during opening of peritoneal cavity by stab incision. - Widening the abdominal wound by scissors while guarding the viscera by fingers. - Exteriorization of the affected organ outside the abdominal wound and wrapping with sterile gauze soaked with warm normal saline. - Surgical manipulation of the affected organ - Returning the organ to its normal position inside the abdominal cavity. - Suturing of the peritoneum and abdominal muscles either together (Small animals) or separately (Large animals) with absorbable suture materials and simple interrupted or horizontal mattress pattern. - Suturing of s/c tissues with absorbable suture materials and simple continuous pattern. - Suturing of the skin with non absorbable suture material and simple interrupted pattern.  Post-operative care: - Application of abdominal bandage. - Administration of systemic antibiotics - S/C administration of antitetanic serum in equine (3000 IU in horses and mules – 1500 IU in donkeys) - Daily dressing of the wound with Povidone iodine. - Removal of the stitches after 7-10 days.  Hemorrhage Causes: - Opening of the abdominal wall (External bleeding) - Improper suturing of the visceral organ (Internal bleeding) Treatment: - Ligation of the bleeders - Cauterization Prevention: - Proper suturing  Post-operative seroma - Post-operative swelling around the wound due to inflammation Treatment: - Systemic antibiotics - Good drainage by removal of the lowest stitch. - Daily exercise.  Infection - Either local or diffuse peritonitis - The severity depends upon; amount of microorganisms, its virulence and the animal's immunity Causes: - Improper surgical asepsis - Dehiscence of visceral suture Treatment: - Intra-abdominal and systemic antibiotics - Suturing of the ruptured organ's sutures. Prevention: - Proper aseptic surgery - Proper suturing  Fistulation - Such as ruminal fistula in bovine and caecal fistula in equine Cause: - Due to improper suturing of the gut which leads to leakage of gut contents and consequently subperitoneal abscess formation. This abscess opens to outside by a fistula. Treatment: - Re-operation for excision of the fistula. Prevention: - Proper gut suturing.  Incisional hernia Causes: - Improper suturing of the abdominal wall - Weak scar tissue formation at the site of surgery. - Increase in intra-abdominal pressure after laparotomy Treatment: - Re-operation Prevention: - Proper suturing of the abdominal wall - Avoid the increase in intra-abdominal pressure after laparotomy  Incarceration of the bowel Cause: - Improper suturing of the peritoneum Treatment: - Re-operation Prevention: - Proper suturing of the peritoneum  Subcutaneous abdominal emphysema -Accumulation of air or gases under the skin at and around the operation's site. Cause: - Improper suturing of the peritoneum leads to escape of the air inside the abdominal cavity to s/c, during the conversion of the positive pressure into a negative pressure. Treatment: - Daily massage of the emphysema. Prevention: - Proper suturing of the peritoneum  Wound dehiscence - Rupture of the stitches with or without prolapsed viscera. Causes - Improper suturing of the abdominal wall - Infection - Vicious animals (licking, biting, scratching of the stitches. Treatment: - Reoperation - Excision of any necrosed tissues. Prevention: - Proper suturing of the abdominal wall. - Application of abdominal bandage - Daily dressing of the wound with antiseptic solution. -  By Prof. Ashraf Abu-Seida 2022  The umbilicus is formed of Two umbilical arteries (Round ligaments of the UB One umbilical vein (Round ligament of the liver) Urachus (Middle ligament of the UB).  Umbilical Infections  Umbilical Hernia  Umbilical Infections and Hernia  Umbilical Eventration  Patent Urachus (Pervious urachus or persistent urachus)  Umbilical Granuloma  Definition  It is a disease of newborn animals like calves, foals, lambs, piglets…etc and characterized by umbilical infection and/or polyarthritis  Incidence  It is usually seen in young calves, in particular less than one week of age (Joint ill).  Navel ill is usually seen in older calves  It is common in males than females due to anatomical consideration (bulls navels tend to dry slower than heifers and they are thus at more risk of navel ill).  E. coli and Strep. spp are the common isolates from the infected joints. Predisposing Causes  Inadequate colostrum intake.  Poor hygiene. Causes  Infection enters via the umbilical cord at, or soon after, birth. This infection can result in various signs depending on where the bacteria spread to.  In most cases of joint ill and septicaemia, bacteria enter through the gut or upper respiratory tract within the first few hours of life before colostrum ingestion. Symptoms Navel ill (Omphalitis/Omphalophlebitis/ Omphaloartertitis/ Urachitis):  If infection stays in the navel, the primary sign is a swollen, painful navel that does not dry up.  Standing with arched back  An abscess may develop or firm cord is present  The calf may have fever and loss of appetite. Joint ill (Infectious polyarthritis):  If infection spreads from the navel, or navel ill is not treated, further signs will develop as bacteria spread via the bloodstream and settle in other parts of the body, particularly the joints.  Fetlock, carpal joints, hock, and stifle joints are commonly affected  The affected joint(s) are swollen, hot, and painful.  The drainage lymph nodes (prescapular or popliteal) are swollen.  Moderate (4/10) to non weight-bearing (10/10) lameness.  Calves with two or more limbs affected adopt a "crab-like" stance.  Muscle atrophy over the gluteal/shoulder regions.  The navel may be thickened and painful.  Temperature will be raised during bacteremia but by the time the disease it may be normal.  Loss of appetite and depression is often seen.  Other sites where bacteria can settle include the eyes, around the heart and the brain. Death is common in the latter cases.  In some calves infection spreads from the navel to the liver causing a liver abscess. Diagnosis  Case history  Clinical symptoms  Clinical examination (Aseptic aspiration).  Ultrasonography  Arthrocentesis to obtain sample from joint effusion for laboratory examination  Radiography has limited application in acute disease  Differential diagnosis  Localized peritonitis, patent urachus and umbilical hernia.  Ultrasonography is useful to for this differential diagnosis.  Fracture of a long bone - trauma to joint/s – osteomyelitis – rickets - muscular dystrophy.  Case history and X-ray examination are useful for this differential diagnosis. Treatment  Early treatment is necessary to prevent the infection spreading.  Infected animals should be separated and treated with broad spectrum antibiotics and pain killers.  Antibiotic treatment (Penicillin) should continue until after the signs have disappeared (7-10 days).  For large navel abscesses, surgical intervention to evacuate the pus is often necessary.  Joint lavage can be performed where one joint is affected and in the early stages of infection Complications  Peritonitis - polyarthritis - meningitis – pericarditis - hepatic abscesses - umbilical hernia - septicaemia - death.  Prevention  Maintain strict hygiene in the calving boxes and until the navel has dried completely.  Proper planning and preparation of the calving areas.  Umbilicus must be fully immersed in strong Povidone iodine solution within the first 15 minutes of life and repeated 2 to 4 hours later.  Feeding young calves sufficient amount of colostrum, particularly during the first 6 hours of age (3 liters of good quality colostrum) even through esophageal feeding.  It is a congenital condition commonly seen in calves and foals.  It may be occur as a result of a membranous urethral diaphragm prevented closure of the urachus.  The patent urachus was complicated by an ascending infection of the intra-abdominal umbilical remnants. Clinical signs  It is frequently associated with omphalitis.  Dripping of urine from the umbilicus  Wet umbilical region  Loss of hair at the umbilicus  Multiple ulcers around the umbilicus  The animal can urinate from the urachus and the urethra. Diagnosis Case history, Clinical signs - Ultrasonography Treatment  Laparotomy  Surgical removal of the urachus and umbilical vessels  Treat the cause such as transection of the membranous diaphragm if present.  It is a congenital anomaly commonly seen in calves, lambs, kids and foals.  It is characterized by prolapse of the small intestines (jejunum) or contained in a sac of peritoneum at the umbilicus.  Often the exposed intestine either ruptures when the animal moves or becomes necrotized due to ischemia in long standing cases, so the prognosis is then hopeless.  Very recent cases (