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SA Sx - Approaches to Abdominal Cavity

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drraythe's version from 2017-09-13 18:53

Abdominal cavity

Question Answer
What is the diff btwn celiotomy & laparotomy?Celiotomy is the more correct term when generally referring to opening the abdomen (surgical incision into the abdominal cavity via the ventral midline), whereas laparotomy refers to a FLANK approach to the abd. Cavity
What are the 4 main approaches to the abdomen (combinations of these can occur)Ventral midline, paramedian, flank, paracostal
*What is the ventral midline approach like? Why do we like it?Most commonly used, *cut through linea alba (he said try to dissect SQ from linea alba before cutting). Used most in sm ani, easiest & quickest to approach/close, minimal bleeding, exposure of all abd organs
What is the paramedian approach like?When you cut to the side of the ventral midline - usually the "oops" cut
What is the flank approach like? Pros/cons?Btwn tuber coxi & last rub- - middle of this distance. Usually vertical incision. (Lateral incision btwn last rib & tuber coxae). It gives you LIMITED access to the entire abdomen; however, is excellent exposure of 1 kidney, 1 adrenal gland, 1 ovary
What is the paracostal approach like? When it used/cons?1-2 fingers caudal to last rib & parallel to it - curved incision - rarely used by itself. Very limited exposure.
Why is a paramedian approach not ideal?Bc you are cutting through the rectus abdominus there is more bleeding, longer closure time, inc exposure of organs on 1 side of the body (may or may not be bad)
What are the 2 kinds of paramedian approaches?(1) Transrectal (cutting through the abd mm)
(2) Pararectal (not going through rectus abdominus muscle. go lateral or medial to it - mm belly will not be touched - reduce bleeding. Easier to close also.)
Hemorrhage vs bleeding vs oozingHemorrhage = LIFE THREATENING CONDITION
Bleeding = not as bad
Oozing = slow capillary bleeds
What’s the thing you might cut if you do a ventral midline approach?Falciform lig (ligament that attaches the liver to the anterior (ventral) body wall.) - Can have some bleeding bc of falciform ligament - fat & adipose tissues & bvs from embryo
What is the GRID approach? What is it good for?Separate mm fibers in direction of their insertion. Split mm fibers instead of cutting through them. Easier closure. Kinda like working through a funnel tho (since pulling apart 3 mm layers). Good for extraperitoneal kidney, or flank castration/ovariectomy but not OVH (each layer must be sutured back independently or it will restrict mm movement). You will need a longer incision on the skin for more room to retract mm
If you hear borborygmi behind the costal spaces, does that guarantee a diaphragmatic hernia?No... Cupula of diaphragm can reach high up - so up to costal spaces there can be abdominal content (3-5 spaces into costal space)
(Combined approaches) Wwhy do we like the ventral midline + paracostal? Why do we not?Increased exposure, especially of gall bladder & liver lobes (right), but more bleeding & longer closure
*(Combined approaches) Why do we like the ventral midline + median sternotomy? Why do we not?Increased exposure of cranial abdomen (liver & diaphragm). However, opens pleural cavity so *assisted ventilation is REQUIRED! Also the sternum must then be closed again, as well as thoracic drainage must be done. (Need a thoracostomy tube to recreate the neg pressure. if not lungs wont expand.)
In the Ventral Midline Approach, what is a landmark that should be incldd in the Sx field?Umbilicus
Exploratory celiotomy opens from where to where?Xyphoid process to pubis
If you do Ventral Midline Approach, what is the skin incision like? What do you do after that?The skin incision should be extended 1cm cranial & caudal to the anticipated body wall incision (prevent incisional hernia). Then SQ layer incised in the same line as the skin. Then the linea alba is identified, tented & incised
In the Ventral Midline Approach, where is the linea alba usually found?At or cr to the umbilicus
What vessels are around the linea that you need to be careful of?Cr superficial epigastric vessels run parallel to the linea cr to the umbilicus
(What 2 grips for cutting midline?) When you are cutting, what must you be mindful of/do?Pencil grip for short precise incisions, violin grip for long incisions. If you're gonna cut, CUT. Dont do little pecking cuts all the way down, you're causing more wounds + more inflammatory processes. Tell the anesthesiologist when you are about to start cutting!
If the surgeon asks for "scissors" which scissors are they asking for?Metzenbaum. All others will be asked by name.
What’s special about the ventral midline approach in male dogs?The penis/prepuce is in the way, so you need to drape the preputial orifice out of the Sx field. (Towel clamp the prepuce NOT PENIS) You will still need to have the skin incision detour laterally to the prepuce. *Preputialis mm. must be severed in half, ends are tagged for later reattachment (if not they pee off to the side). The incision returns to midline after branches of caudal superficial epigastric vessels are ligated
Whats some stuff you see when you 1ST open the abd?Omentum
Spleen crossing over
Maybe greater curvature of stomach
1st things you see when abd opened → which way do you want to move the omentum? What should you keep in mind when moving the spleen?displace omentum cranially or laterally. Spleen attached via gastro-splenic ligament - move gently
How would you go about cutting to get through the linea alba?Lift up S w/ forceps & separate SQ from linea alba. Then can do blade cutting to expose linea alba. Tent linea alba before cutting & pierce linea alba. Grooved director can be used to cut cranial & caudal to increase incision length protects internal organs. Can use finger in a v shape if have no grooved director like pic in middle. Use Belfour abd retractor
How does a cat's linea alba compare to a dogs?Wider & thinner linea in cats
(Landmark on the L or R of abdomen?)Cecum on the right. Left is descending colon
What are the 2 natural retractors of the abdomen?Duodenum (R hand side). On L had side, descending colon - more moveable, better retraction on L then. Both allow you to check vertebral gutters - bc need to check ovarian pedicle before closure
**What is the HOLDING LAYER of the ventral body wall in the ventral midline approach?*External rectus fascia. Only layer need to incld in closure of linea is this one!! (Dont bother w/ the internal sheath - doesnt add strength & might inc adhesion risks. ALSO dont suture rectus mm layer, just czs inflammation)
How do you treat the closure of a ventral midline approach, if it's on the midline? If mm is exposed? How are sutures placed?Midline = fill thickness bite. MM = external rectus sheath (fascia) only part incldd in bite. Sutures are placed 3-5 mm apart & incorporate 3-5 mm of tissue.
Ventral midline approach - if doing a simple interrupted closure (linea alba), what kinda suture & size? (sp diff?)Monofilament absorbable or non-absorbable suture (PDS), Size 3/0 to 0 in dogs, 3/0 or 4/0 in cats (cats = smaller)
Ventral midline approach - if doing a simple continuous closure (linea alba), what kinda suture & size? (sp diff?)Monofilament synthetic absorbable or non-absorbable suture (Do not use chromic gut or stainless steel suture in continuous pattern in linea alba!), size 3/0 to 0 in dogs, 3/0 or 4/0 in cats
What are 2 different ways you can do a Simple continuous closure w/ the ventral midline approach?(1) Start at 1 end & close at the other end of the incision
(2) Start at each end & close toward the center of the incision. Tie 2 sutures together at center of incision
How is the SQ tissue closed in a ventral midline approach? (Skin?)Subcutaneous tissue is closed in simple continuous or simple interrupted pattern, using 2/0 to 4/0 synthetic absorbable suture (In the male dog the preputialis muscle must be accurately apposed!) (Skin is closed w/ 3/0 or 4/0 nylon)
Reasons for stitches to rupture#1 cz - too tight! (Ischemia → tissue death → no strength → pop sutures)
Why do you want to/ how can you help reduce dead space when doing your SQ closure on the ventral midline incision?To reduce dead air space that will fill w/ serum or fluid (hematoma) to reduce Infnxn. So when taking bite of SQ - grab bite of rectus fascia
What suture material should you not use when closing the linea alba in a continuous pattern?*No chromic gut or stainless steel
If you are closing the ventral midline incision on a MALE dog, what do you absolutely need to remember to do?*Suture back preputialis mm (or theyll pee sideways)
When would you want to use an interlocking (ford) suture on a ventral midline incision?Lg animals that need a better hold
(Someone else’s notes said) What kinda suture patters would you want to avoid when closing midline?Things that cz tension like mattresses that will cz everting
***Which approach is used for increased exposure of the gall bladder & right liver lobes?VM + Paracostal
***Which approach is used for Exposure of Cranial abdomen (Liver/ diaphragm)?VM + Median Sternotomy
***True or False - VM + Median Sternotomy requires assisted ventilationTrue - you have created a pneumothorax along w/ assisted ventilation a Thoracic drain must be placed to regain neg pressure
***With the VM approach how far should the skin incision be extended cranial & caudal to the anticipated body wall incision?1 CM
***In Dogs, the linea alba is most easily recognized.... where?**At or **Cranial to the Umbilicus
***In Male Dogs, during VM approach, what muscle is severed in half & must be reattached before the end of your procedure?Preputialis mm
***What is the holding layer of the Ventral Body Wall?External Rectus Fascia
***When closing the VM incision how should you place your sutures...?New notes say 3-5mm apart & 3-5mm deep
***What suture pattern will you use when suturing back the preputialis mm.?Cruciate pattern is the best for muscle
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