SA Sx - Exploratory Celiotomy
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drraythe's
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2017-09-13 18:57
Exploratory
| Question | Answer |
|---|---|
| Why would you want to do an exploratory celiotomy in an abdominal trauma PTx? | Dont just pack inside & suture, dont know how much damage has been made or how much contamination is done |
| Indications for an exploratory celiotomy? | Dx, prog, indicates therapy, most efficient path (Dx tool) to a definitive Dx |
| Indications → how does fluid accumulation appear on radiographs? | "Ground glass appearance" |
| Indications → example of non-responsive pain youd want to explore further? | Colic |
| Indications → examples of what Abnormal discharge might mean/why youd want to check it out? | Bladder Uterus Fistula |
| What should creatinine levels be like in the abd cavity fluid? | Normal value of creatinine in abdomen in 0, creatinine is not free floating, only find if rupture of bladder/urethra |
| What is a lap sponge? How do you use it? | Big, thick pieces of gauze w/ a little goose string that should stay outside of PTx to remind that something has been placed in cavity |
| What is optimization? | Reach best stabilization you can before Sx (but theyre not totally stable) |
| What is a DPL & why might it convince you to do an exploratory? | Diagnostic perineal lavage - insert warm LRS, roll PTx around & get sample for preliminary Dx - if you see possible tumor cells etc you might wanna go in (more accurate to determine types of fluid in abdomen than FNA) |
| Which is usually more desirable as a scrub - chlorohex or betadine (Povidone-iodine)? | Betadine is inactivated by organic material & alcohol & chlorohex lasts longer & has a little bit of antifungal activity so usually prefer chlorohex |
| What is a Trendelenburg setting & why/when do you use it? How is the PTx layed on this? | This is when the table is tilted so the head is lower than the feet - which is great for Ca abdomen stuff since the organs slide cr. The REVERSE Trendelenburg is when the head is higher than the feet & this is good for Cr abdomen things since organs slide Ca. *Dorsal recumbency most common |
| If you use a Trendelenburg setting, what should you tell the anesthetist? | Tell anesthetist that there will be an upload? So viscera will be displaced cranially so diaphragm will be overloaded |
| When might you want to add a paracostal approach to your ventral midline approach when opening the abdomen? | In case you need better exposure in the cranial abdomen, need for gallbladder & liver Sx |
| What is the approach (where/how do you cut) for an exploratory celiotomy? What should you avoid? | Ventral midline approach from xyphoid to pubis. He said NO keyhole incisions for this. (Paracostal incision? ← i think he means consider this in combination possibly) |
| What are the instruments you will need for your exploratory celiotomy? | Balfour or Gosset retractors Gelpi retractors Lap sponges Suction Doyen intestinal forceps Electroscalpel Delicate thumb forceps |
| How can Balfour retractors be used? | Good for keeping abd open & keep hands free  |
| What should you know about contamination? | CONTAMINATION IS NOT INFXN! Contamination of 65000 bact per hour. 10^6 BAC per gram of skin to be classified as Infnxn. No ABx given for contamination, just Infnxn. (pre - ABx - given 1 hr to 30 min pre Sx & then repeated 90 min later in Sx) |
| After entering the peritoneal cavity what should you obtain while youre in there? | Obtain samples of free fluid |
| What is the technique you should use to explore the abdomen? | Begin cranially w/ diaphragm & work through all 4 "quadrants" (L, R, Cr, Cd). Always use same technique & be consistent, efficient. Use your anatomical retractors (some people use gastroepiploic line as differentiation btwn cranial & caudal) |
| What are the anatomical retractors? | Cecum (R) & descending colon (L) |
| Picture of structures to observe on technique |  |
| After thorough exploration, if surgical Dx is not possible, what do you wanna do? | Obtain MULT biopsy samples |
| What order do you want to take your biopsies in? | 1st, tissues w/ the least potential for contamination. Last, tissues w/ greater contamination potential |
| Excisional biopsy vs incisional biopsy | Excisional is when you take the whole lesion out. Incisional is when you take out only a part of the lesion, along w/ a little bit of the healthy tissue surrounding it |
| What are margins like in an excisional biopsy? | Safety margin 1-1 1/2 cm all way around & deep. (Mark edges L , R, Cr, Ca & make sure go at least 1 full tissue layer deep)  |
| Why might an incisional biopsy be useful? | Would be able to tell is there a boundary or has the Dz gone beyond it? |
| Commonly biopsied organs? | Liver Intestines Lymph nodes Kidneys Prostate |
| 6 ways to biopsy the liver | Finger crushing, Ligature Fx technique (Guillotine), Instrument fragmentation, Wedge resection, Biopsy punch, Tru-cut |
| Once you have a sample of the tissue biopsied what should you always do? | Keep it moist (wet sponge or something) |
| What is nice about the ligature Fx technique (Guillotine) for biopsying the liver? What isn't so nice? | Cuts parenchyma but not billary ducts or vessels  Efficiently performed, however, requires surgical assistant & is Limited to sampling margin of hepatic lobe |
| How is Hemostasis achieved after a liver biopsy? | With Surgicel®, Vestron® or omentum |
| How do you close a Wedge resection? | Need mattress stitches to suture back to approximate edges  |
| If you are going to biopsy the intestines, how much should you take? & in what fashion? (How long, how many, how should you be careful?) | Do not exceed 20% of intestinal circumference, Obtain multiple samples along length of intestine that are full thickness & ~1cm long, Preserve luminal diameter & Protect properly closed site |
| If you are going to biopsy the intestines, how do you close? What can you do to make the closure a little more leak-proof? | Single layer closure w/ a simple apposition pattern. You can use Omental or serosal patching |
| If you take a biopsy of the intestines, how can you close to preserve or increase the lumen? |  |
| Do you want inverting, everting, or simple apposition for intestinal biopsy closure? | SIMPLE APPOSITION, not enough lumen room for an inverting (simple interrupted shown in pic) |
| After you have closed your biopsy of the intestine, what should you check & now? | Water test to check for leaks to see if suture is patent (inject saline into lumen near site of closure). Only do small amt of water bc low pressure system so if add a lot will obviously have a leak |
| 3 common lymph nodes that are biopsied in the abdomen? | Mesenteric External iliac Colic |
| 3 most common ways to do a biopsy on a LN? Is 1 preferred over another? | FNA Wedge Excisional. Excisional techniques preferred to FNA  |
| What are some reasons an excisional biopsy is preferred for a LN? | Provides morphologic information, Preserve regional blood supply (Ligate blood supply), Minimal handling |
| What is Finger crushing liver biopsy technique like? | Grab piece of lobe & squeeze parenchyma & break parenchyma but not vessels |
| Best method of liver biopsy is? How do you do it? | Ligature Fx (guillotine) wrap a piece of suture, make a loop & tie not all the way down & squeeze |
| What must you be very careful of when doing the ligature Fx technique? | (guillotine) be sure theres no biliary leak - leak of bile can lead to chemical peritonitis which can be generalized & then go to septic peritonitis |
| What is omental/serosal patching? When do you use this? | For intestinal biopsy, place omentum on top of suture line & it'll adhere |
| Once you have gotten your intestinal biopsy, how do you handle it? | Dont squeeze sample w/ thump forceps or else you'll destroy the tissue put it in a wet sponge & give to someone |
| Is a dermal punch of the intestines partial or full thickness? | Full |
| What is a water test? | Inject 5 cc of saline into intestinal lumen & keep it clamped to see if theres a leak & squeeze it gently must do every time you open or resect intestines |
| What should you be careful of when biopsy the kidney? | High pressure system, be careful not to damage any time you enter the cortex (tru-cut or cylinder cut) |
| How should you do a needle aspiration on the kidney? | Caudal to cranial parallel to the cortex |
| How do you achieve hemostasis for a kidney biopsy? | Digital pressure to achieve hemostasis, Omentum or oxidized cellulose to maintain hemostasis |
| What are the risks of a wedge resection w/ the kidney? | HGE |
| How do you close a kidney biopsy, cautions? | Can close w/ Mattress or continuous, it is a high-pressure system so be careful when suturing or else guillotine |
| What should you absolutely know about the anatomy of the prostate? | The urethra goes through it!! Don’t cut this! |
| What can you manipulate to help reach the prostate? | Exteriorize urinary bladder |
| Which part of the prostate should you avoid, aside from the urethra inside? | Avoid dorsal aspect - sometimes when enlarged may be invading the trigonal area (the blood supply & fnxnal area of the bladder) |
| What are the 2 ways you can try to biopsy the stomach & pros/cons of each? | Endoscopy less invasive but can't get full thickness. Exploratory celiotomy allows full thickness biopsy, but is more invasive |
| Two ways to biopsy spleen? | Partial splenectomy or wedge resection |
| How do you biopsy the pancreas & WHERE? | Partial pancreatectomy, distal aspect (use the most caudal aspect of R or L arm of the pancreas - R is easier to access) |
| Do you want partial or full thickness biopsy of bladder? How do you close? | Full thickness, 1 or 2 layer closure (one is simple apposition, 2 layers would be a Connell or Cushing combination) |
| What might pearls on the omentum indicate? | There has been trauma - might find lacerated or severed but already healed spleen |
| Which part of the omentum would you want to biopsy? | Distal aspect |
| What should you ALWAYS do after major abdominal Sx? | LAVAGE the abdomen, immediately prior to abdominal closure. Indicated whenever peritoneal contamination has occurred |
| What might you want to add to your abdominal lavage solution? | Add heparin to lavage solution (100 micrograms/kg)??? → increases survival & significantly reduces abscess formation in experimental peritonitis |
| Big benefits of abdominal lavage before closure? | Removal of contaminants (tissue fragments, fibrin clots, fat, bacteria), PTx warming (use warm fluid), |
| What fluid do you use for an abd lavage? When do you know to stop lavaging? | Use Isotonic fluid, repeat lavage until retrieved fluid is clear |
| When would you not completely close the abd after exploratory? | Perform unless open peritoneal drainage provided |
| What SHOULD you incorporate in your abdominal closure, what should you not? | Incorporate only external abdominal fascia - *Avoid rectus abd. Muscle in suture (and don't incorporate internal sheath, doesnt help at all) Paramedian incision closed the same way. |
| Why do you want to do too much saline in your lavage? | Too much saline flush bad, body’s defenses cant keep up (floating in saline & cant get to the contaminants) |
| What should you be careful to esp do w/ a pancreatic biopsy? | Ligate pancreatic duct thoroughly - otherwise leak - saponification of fat & chemical peritonitis focally into generally then bacterial peritonitis & then septic peritonitis |
| ***What position will you use for Exploratory Celiotomy biopsy technique? | Trendelenburg + dorsal recumbency |
| ***Which position will displace organs inside to push against the diaphragm? | Trendelenburg (NOT REVERSE) |
| ***What is the most important respiratory muscle in animals? | Intercostal muscles |
| ***Which retractor has a spoon? | Balfour |
| ***True or False - when doing an exploratory celiotomy biopsy you want to obtain the tissue w/ greater contamination potential last | True *1st tissues w/ least potential for contamination* **Also, Neoplasia... you don’t want to spread it... do it last** |
| ***What is the safety margin for biopsy? | 2cm all the way around & depth wise! |
| ***When performing a biopsy of the intestine what % of the intestinal circumference should you not exceed? | Do NOT Exceed 20% of the intestinal circumference! |
| ***What suture pattern will you use when suturing the kidney after a biopsy? | Mattress or Continuous |
