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SA Sx - Gastric Sx

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drraythe's version from 2017-09-13 18:59

Gastrotomy

Question Answer
Where might you find part of the stomach that is not fully visible?Stomach is partially hiding under the cupula of the diaphragm.
If you are manipulating the stomach, which ligament should you be very careful of when cutting & why?gastrohepatic ligament - careful cutting it or you can get the bile duct
How much of the stomach is on the L side? R side?Stomach is 2/3 on the left side, 1/3 on right
What angle do you cut linea alba at & how to you extend incision?Cut linea Alba at 45-degree angle & open w/ grooved director
When do hiatal hernias happen?Hiatal hernias occur when the contact btwn esophagus & fundus isnt good
Which side does the fundus of the stomach live on?Left
Esophagus connected to what part of the stomach?Cardia
When you gastropexy where do you attach to stomach, where do you attach to wall?Gastropexy you use the pyloric atrium to adhere to the right wall (if GDV)
What happens if rugae in pyloric antrum get too big?Probs w/ emptying stomach
Where does the pancreas sit?Btwn duodenum, greater curvature & colon
What are the 2 ways/tools you can take the stomach out?Fingers or Babcock forceps
What should your approach be for a gastrotomy?Ventral midline - Start incision immediately caudal to xyphoid process, usually to umbilicus (or 1-2 fingers past) (Extend caudally as far as necessary-longer incision in deep chested dogs)
If you wish to use stay sutures to manipulate the stomach, where should you place them?Stay sutures are in btwn greater & lesser curvature (fundus & pyloric antrum) & should place stay sutures for the length of your incision to work as handles to pull out/retract the stomach (2° stay sutures can be placed to be able to have a better opening = remove for FB)
*What are used to elevate the stomach to a cranial midline abdominal position?Babcock forceps or stay sutures
Why do you want to place lap sponges around the stomach?Place sponges to keep edges moist, also absorb spillage to prevent it from going into ad cavity
Where do you want to make your 1st stab incision into the stomach & why? (How do you continue incision?)Tthrough hypovascular (not avascular) area on ventral body of the stomach into the gastric lumen midway btwn greater & lesser curvatures, far from pyloric antrum as possible - Metzenbaum scissors lengthen the incision.
Do you want full thickness stay sutures? ExplainSera muscularis separate from mucosa & submucosa so you dont take stay sutures all the way through when just general stay sutures (can put through mm for 2° stay sutures to manipulate opening)
If you don't feel slippage of the muscularis from the mucosa/submucosa, what is your concern?Mucosa & submucosa may be gone = sloughing of tissues in GDV
What is the "mushrooming" effect you see when you cut into the stomach?The mucosa tends to mushroom out when you cut through - normal
What are the 2 options for closure of the incision into the stomach?(1) 2 inverting layers (Connell following by Cushing or Lembert)
(2) Simple continuous in the mucosa/submucosa, followed by Cushing or Lembert
Would you rather use 2 inverting layers, or a simple continuous & then an inverting layer for stomach Sx?Simple continuous in the mucosa/submucosa, bc simple continuous allows for good hemostasis bc throughout the operation the stomach tends to ooze & you cant see edges
Explain Connell vs Cushing vs Lembert patternsCONNELL incorporates all layers of gastric wall. Suture line begins & ends slightly beyond the limits of the incision. CUSHING/LEMBERT through all layers of gastric wall except mucosa, begin & end slightly beyond incision limits (not fully penetrating)
Do you want absorbable or non-absorbable suture for the stomach?Absorbable
How do you know you have a good inversion for your closure?Want serosa-serosa contact
How should you remove stay sutures from the stomach?Remove the stay sutures by making a cut close to the viscera on 1 side & pull through the other so you only have a few mm go through viscera (less damage)
What are the abdominal retractors & which arent?Belfour & army/navy are abdominal retractors, not gelpis
***What is the holding layer of the closure of the stomach?*Submucosa
What can you see to tell if your closure shows good inversion & serosa-serosa contact?Knuckling pattern
When doing stomach closure, stay away from what?Stay away from greater curvature, or you can compromise blood supply
Where is the gastrohepatic ligament?Just above the bile duct - use caution!
Whats a URFO?Unintended retention of foreign objects - check yo shit
Should you NPO (nothing per os) your PTx after stomach Sx, or should you feed them?Used to say NPO for 12-24 hours, but now we tend to feed PTxs ASAP bc glutamine is important for survival of enterocytes (villi will atrophy)
Some ways to maintain hydration while PTx recovers from gastrotomy?Intravenous fluids, pre-loaded fluids or subcutaneous fluids
When can you offer water PO?Offer small amt of water at 12-24 hours (can give them ice cubes w/ good sources of K+ (Gatorade))
When can you start to offer food after gastrotomy if no vomiting?If no vomiting, offer small volume of bland digestible food or a low residue diet like AD about 1-2 hours later
When can you start to offer food after gastrotomy if there is vomiting?If vomiting occurs, NPO for several hours, then start w/ small amt of water, etc
How should their diet be altered initially after Sx & when can it start to go back to normal?Feed small frequent meals, Gradual return to normal diet over 2-3 days
When does dehiscence usually occur?3-5 day dehiscence occurs - so know by 3-5 days if will get better or worse
***What is the Holding Layer of the Digestive Tract (Esophagus to Rectum)?Submucosa
***Which would be an incorrect closure for Gastrotomy? (a) Connell followed by Cushing (b) Simple continuous followed by Lembert (c) Lembert followed by Connell (d)Connell followed by LembertLembert followed by Connell would be WRONG [1. 2 inverting layers: Connell followed by Cushing or Lembert (Inverting perforating → Inverting non perforating) 2. Simple continuous in the mucosa/submucosa followed by Cushing or Lembert]
***True or False - When you see knuckling after an inverting pattern you know that the suture was done incorrectly & will leakFalse - Knuckling is an excellent thing to look for after doing an inverting pattern. It will tell you that there is good inversion & no tissue layer will come out.
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