Exploratory Celiotomy Lecture Notes PDF

CVM 737-A Introduction to Surgery Exploratory Celiotomy Lecture 21- 1 Lecture Hour January 23, 2025 R. Randall Thompson, DVM, MSpVM (SA Surgery) Liaison, DeBusk Veterinary Teaching Center Associate Professor of Small Animal Surgery  Learning Objec...

CVM 737-A Introduction to Surgery Exploratory Celiotomy Lecture 21- 1 Lecture Hour January 23, 2025 R. Randall Thompson, DVM, MSpVM (SA Surgery) Liaison, DeBusk Veterinary Teaching Center Associate Professor of Small Animal Surgery  Learning Objectives 1. Explain the anatomic structures involved and method used to retract intestines to facilitate inspection of and access to the left and right “gutters” when performing an exploratory celiotomy. 2. Describe the surgical approach to the abdominal cavity for performing an exploratory celiotomy on both a male and a female canine patient. 3. Identify the proper minimum length of time to observe a trauma patient and the reason for the observation time. 4. Evaluate a case and recommend the proper use of prophylactic antibiotics intra-operatively.  Learning Objectives 5. Given a clinical case presentation, identify the appropriate fluid for use for intra-operative lavage of the abdominal cavity. 6. 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. 7. State when a sponge count should be performed. 8. Identify failure to complete the entire exploratory sequence as a major cause of complications and overall failure of successful outcomes when performing exploratory celiotomies.  Definitions Celiotomy - incision into the abdominal cavity Laparotomy - flank incision "midline laparotomy" = no such thing as (kittens puppies Cattle from this perform some spays approach - can , , Acute Abdomen - sudden onset of signs · ex appendicitis Skagn (distention, pain, vomiting) referable to the distention abdomen Abdominal Evisceration – herniation of peritoneal contents through the body wall with exposure of the abdominal viscera Reasons for Abdominal Exploratory Diagnostic - Try to ID problem Biopsies Visualization Therapeutic >CorrectingSomething/nown a - proble Gastric dilatation and volvulus Severe hemorrhage Colonic perforation Foreign body removal Evisceration #1 cause of postoperative major abdominal evisceration in a recent study ? (Gower et al, JAVMA 234:1566, 2009) Ovariohysterectomy (OHE) ! Likely just a reflection that it is one of the most frequently performed abdominal procedures in small animals. Sage Advice… Unnecessary surgery must be avoided but surgery cannot always be delayed until one is certain that the patient will benefit from it. Give me a surgeon who is bold enough to cut, and smart enough to stop! - J. Patrick Hudspeth, D.V.M.  Free advice is worth everything you paid for it…sometimes more. Make a list of the samples desired and the diagnostic procedures to be performed. Prioritize the list unexpected (e case of anesthesia in emergency) > -. Discuss the list with the primary clinician ① Take the list to the OR and use it. To cut or not to cut… that is the question. Preoperative Management History Physical Exam Findings Radiographic Studies Ultrasonic Studies Laboratory Findings  Physical Exam Findings - Beware! Depressed/lethargic animals may not show pain. Hemorrhage may not show up for 3-4 hours (splenic or liver lacerations), so observe trauma patients for ≥ 8-12 hours. R If Bp too low arrival to bleed then upon Mesenteric avulsion or ruptured biliary tract may not be evident for 1-2 weeks  General Observations Attitude and posture of patient Temperature Respiratory rate and effort Heart rate and rhythm Abdominal auscultation, percussion, & palpation Serial physical exams Further Preoperative Management Intravenous catheter Blood samples Hematocrit Total protein Glucose Blood Urea Nitrogen Complete blood count Other tests as indicated Further Preoperative Management (cont.) Urine collection Cystocentesis Ultrasound guided Palpation guided Blind Stick Catheterization Indwelling catheter to measure urine output Further Preoperative Management (cont.) Radiographs Peritoneal fluid (blood, urine, peritonitis,…) Accumulation of air Radiographs nondiagnostic? Perform: Abdominocentesis Diagnostic peritoneal lavage (DPL) FAST Exam - Focused Assessment with Sonography in Trauma Further Preoperative Management (cont.) Correct electrolyte imbalances and hydration prior to surgery when possible  Critical Owner Communication! 1. Mention the chance of post-op infection 2. Mention the possibility of wound dehiscence 3. “There is a chance that we may not find any gross abnormalities in surgery.” 4. “There is a chance that he/she won’t make it through the surgery.” 5. “There is a chance that we could find something so bad, that I will need to speak with you during surgery” (i.e. neoplasia so extensive that we decide not to wake him/her up)  & Critical Owner Communication! If you take the time to speak with the owner about these things before surgery, the owner is much more likely to deal with these situations better, should they occur.  Anesthetic Considerations Underlying disease Age of animal Condition of animal Length and type of surgical procedure Remember pain management  Antibiotic Considerations Underlying disease Animal’s overall general health Length and type of surgery – Surgeries less than 1 ½ hours, without opening a NAVLE ⑭ contaminated hollow viscus, do not GIT absess etc.. S G , ↳. usually warrant prophylactic antibiotics. Surgical setting (OR vs. field conditions)  L V Ready, Fire, Aim! Suction (Poole or Yankauer tip) appropriatesuppliesthatmaya Retractors (Balfour, malleable) Mixter (right-angle) forceps Laparotomy pads & 4x4s (with markers) Warm saline & bowl (copious amounts) Biopsy equipment/instrumentation Tools supplies > - punch , , scalpel for excised blood etc. , Sample , Formalin etc. , Culture & Sensitivity Drains Surgical Anatomy  Freshman (First Year) Anatomy vs. Surgical Anatomy First year anatomy is like taking a car apart and naming the parts as you do it. Surgery is like repairing the car while the engine is running  Surgical Anatomy It’s a lot more important to know where a nerve lies in your surgical field, even if you can’t remember the name of that nerve, than it is be able to correctly name the nerve that you just severed! If you don’t know it at this time, ideally, you will come to know both the name and the location… …it REALLY counts now!  Surgical Anatomy Quote from a member of the LMU CVM Class of 2018, heard during a live tissue surgery lab: “It appears that Anatomy is coming back to bite me in the @$$ !”  Surgical Anatomy for Surgeons Rectus sheath (external/internal leaves) Rectus abdominus m. External/internal abdominal oblique m. Transversalis fascia Transversalis abdominus m. Peritoneum Differences between cranial vs. caudal?  Surgical Anatomy for Normal Veterinarians The white line means “cut here.” umbilicus because it becomes thinner back near the pubis ① The linea alba is easier to locate near the  Canine Linea Alba The linea alba is the site of insertion for the external abdominal oblique muscle (via the rectus sheath) In the average adult canine, the linea alba is about a cm wide and a mm thick at the cranial location (just caudal the xyphoid). However, at the caudal end of the linea alba (just cranial to the pelvis) it is about 1 mm wide and much thicker.  - · for aim midline (avoid muscle)  Surgical Technique Ventral midline incision Prep big! (Include caudal thorax and inguinal areas) Always count sponges before incision and before closing. No kick buckets The missing sponge is with the biopsy dummy! check hands of all staff present - - check under prepuce of male dogs  Surgical Technique “Go big, or go home!” Incision is from xyphoid to pubis to explore all abdominal organs (can be adjusted by case). fpaint istoexplorethen you ais I  Tips on “Prepping” It is critical that your technicians do a good job prepping! Nice even shave margins No razor burn No cut nipples  Tips “Closing” It is also critical that you do a good job closing the surgical wound Wound edges nicely apposed Nice, evenly spaced sutures No thumb forceps bruises on the skin If it looks bad on the outside, your clients will assume that whatever you did on the inside must be bad too!  The only veterinarians who have never been off of midline are those who have never done surgery! We can deal with it WHEN it happens. E it will happen  Congratulations… It’s a Boy! Clip that hair Flush the prepuce with antiseptic solution before the sterile prep Chlorohexidine diacetate 0.05% (1:40) Povidone-Iodine 1% or 0.1% (1:10 or 1:100) Clamp the prepuce to one side with a towel clamp (Drape the tip of the prepuce and clamp outside of the surgical field.)  Congratulations…It’s a Boy! Clip that hair Flush the prepuce with antiseptic solution before the sterile prep Chlorohexidine diacetate 0.05% (1:40) Povidone-Iodine 1% or 0.1% (1:10 or 1:100)  But I really wanted a little girl this time! The tip of the prepuce and towel clamp are draped out of the surgical field.  But I really wanted a little girl this time! Xiphold > - prepuce · Just cranial to the prepuce, curve your midline incision to the side opposite the clamped prepuce. Ifsuperth/fmeach send Incise the SQ tissues and prepucialis m. Ligate or cauterize veins at cranial prepuce superficial epigastric a -  7 - closetoappa rough it  It’s all the same to me. Retract the incised skin and SQ tissues and locate the linea alba SQ tissues must be incised or undermined and muscular fascia identified before locating the linea alba Now just cut on the little white line – Male or female, you will enter the abdomen ⑧ through the linea alba.  Cover me…I’m going in! After incising xyphoid to pubis… Sharp/Blunt dissection of SQ tissue to fascia Ligate and cauterize small SQ bleeders. Avoid mammary tissue in lactating patients. Identify the linea alba at Tent the abdominal wall & sharply incise the linea alba with a scalpel blade.  Slip sliding away… Palpate for adhesions Extend incision with scissors (mayo) Digitally break down one side of the falciform ligament or excise it. Cautery works well May need to ligate at cranial end Removing the Falciform Ligament With Electrocautery Removing the Falciform Ligament With Electrocautery  Kat I’ve got CSS again! Lights adjusted? Falciform ligament removed? Balfour retractors in place? Excess fluid suctioned out of field? Hemostasis adequate? Just because you don’t know what it is doesn’t mean you can’t see it! There’s a method to my madness. Use a systematic exploration Develop a technique and stick to it (unless the clinical situation dictates otherwise) There is no one best technique. Don’t quit until the job is done! Just because you found a major problem doesn’t mean that it is the only one &  It’s a technique. 1. Explore the cranial quadrant. 2. Explore the caudal quadrant. 3. Explore the intestinal tract. 4. Explore the gutters.  Explore the cranial quadrant. Examine the diaphragm ( including esophageal hiatus) and entire liver (palpate) Inspect the gal bladder & biliary tree, then express the gal bladder not - easy ducts enough to fill should express - Examine the stomach, pylorus, proximal duodenum, and spleen Both head Ital & look · lift spleen ↓ Caudally m (r Limb). Examine both pancreatic limbs, portal vein, hepatic arteries, and caudal vena cava  Explore the caudal quadrant. Descending colon Urinary bladder Urethra Uterine horns or prostate Inguinal rings  Explore the intestinal tract. Palpate and visually inspect from duodenum to descending colon Observe mesenteric vasculature and nodes (both sides) · observe visually d physically Don’t get sidetracked and forget to inspect the entire length!  Explore the gutters. Will be asked during ⑪ 3rd ! - Tive surgery year Right Gutter Use mesoduodenum to retract Center/midline intestines - retractTowards Palpate the right kidney Examine the right adrenal gland · Dont Squeeze ! Examine the right ureter Examine the right ovary or stump  Explore the gutters. Left Gutter Use descending colon to retract intestines Palpate the left kidney Examine the left adrenal gland Examine the left ureter Examine the left ovary or stump = How to find dropped pedicled bleeders  Did you remember to… Complete the entire exploratory? Check your prioritized list? Recheck your biopsy sites? Lavage the abdominal cavity? Generalized infection Diffuse intraoperative contamination Remove lavage fluid?  D Lavaging the abdominal cavity Always use warm lavage fluids (not room temperature) to avoid hypothermia and decrease the chances of post-op infection. There is no evidence that adding antiseptics to lavage fluids is of benefit. It may actually be harmful in the case of povidone-iodine with peritonitis (inhibits macrophage chemotaxis) There is no substantial evidence that adding antibiotics to lavage fluids is of benefit.  Before closing, did you remember to… Inspect the abdominal cavity? Foreign material Surgical equipment Complete/reconcile/record your sponge count?  “All OK Jumpmaster!” Abdominal wall closure 1. Linea alba 2. Subcutaneous 3. Subcuticular 4. Skin  Linea alba Simple Continuous Does NOT increase the risk of dehiscence Secure knots (6 –8 at each end) Appropriate suture material (strong absorbable) Rapid closure Less suture material Interrupted  Dos and Don’ts when closing. Do: Tighten suture enough to appose tissues Incorporate full thickness bites if on midline Use external rectus sheath if off midline Use an absorbable suture in a simple continuous pattern in subcutaneous tissue Reappose the prepucialis muscle fibers in males (If you can. You will know.) Use nonabsorbable skin sutures or staples  Dos and Don’ts when closing. Don’t: Don’t strangulate tissues with suture Don’t damage tissues with forceps Don’t incorporate falciform ligament between fascial edges Don’t include muscle when closing external rectus sheath Don’t attempt to include peritoneum  More than one way to skin… Sutures/staples vs. No sutures/staples Close “good” when the animal is bad! Not for exotics “Hey y’all, watch this!” Glue is not a substitute for good technique Absorbable suture in skin isn’t absorbable  Complications Dehiscence ① When is it most likely to dehisce? 3-5 days post-op (whene home) Suture breakage Knot slippage Pull-through Increased rate of dehiscence with… Wound infection Fluid or electrolyte imbalances Anemia Hypoproteinemia Metabolic disease Immunosuppression Corticosteroids Increased rate of dehiscence with… Abdominal distention Chemotherapy patients Radiation therapy patients Improper surgical technique  Delayed healing may occur Debilitated Very young Very old  Small Animal Surgery Fifth Edition CHAPTER 19 Theresa Welch Fossum, DVM, MS, PhD Laura Pardi Duprey Copyright © 2018 by Mosby, Inc. an affiliate of Elsevier Questions?