SA Sx - Intestines 2

drraythe's version from 2017-09-15 00:35

Obstruction (intuss)

Question Answer
Def of Intussusception?Telescoping of 1 segment of intestine (intussusceptum) into an adjacent section (intussuscipiens)
What is the intussusceptum? What is the intussuscipiens?Intussusceptum = The part INSIDE the intuss.(blue)
Intussuscipiens = Part OUTSIDE of the intuss (red).
Of the intussusceptum? Vs the intussuscipiens, which part is usually the proximal segment? When might be an exception?Usually Intussusceptum (INSIDE PART) is the prox part - unless there was reverse peristalsis leading to reverse telescoping
Intussusception is most common for what age? What is it usually associated with?More common in puppies, Associated w/ hypermotility of gut
What CSs might you see w/ Intussusception & what problems can it cz to the intestines?CS: Bloody diarrhea may accompany vomiting & abdominal pain (often palpable). Damage to the intestines is usually comes from Results in venous occlusion, may progress to perforation & peritonitis
What’s going on here? Radiographic evidence of Intussusception
How would you know w/ contrast if there might be an intuss.?The contrast suddenly moves off to the sides, implying there is something in the middle pushing it off to the sides
What might an intuss look like on transection w/ a U/S?Bullseye
How might you be able to manually fix intuss? When would you wanna do this? What things should you look out for?Gentle traction to take back intestine - can try to massage or milk from outside (esp if no adhesions & just occurred) make sure to check for parasites & watch to make sure it does reoccur (some of the damage may be able to recover)
What’s the 1 bright side to having an illeo-colic intuss?The cecum usually acts as a stopper
In what cases are a resection & anastomosis indicated w/ an intuss?If intussusception is irreducible or intestine is necrotic, resection & anastomosis is indicated
After you reduce a intuss, why might the mesenteric LNs be big?Inc venous return

Obstruction (torsion)

Question Answer
Common signalment of mesenteric torsion?Medium to large breed dogs, especially German shepherds & Pointers. Adult males most commonly affected
How quickly can a torsion become a huge problem?May evolve from clinically normal to dead in a few hours - CSs are per-acute to acute, associated w/ partial obstruction & ischemia of intestine
*Predisposing factors for mesenteric torsion?Vigorous activity
Dietary indiscretion
Recent GI Sx
Foreign bodies
Exocrine pancreatic deficiency
How quickly do CS of mesenteric torsion present & what are some of the CS?Per-acute to acute & associated w/ partial obstruction/ischemia:
Acute pain
Mild abdominal enlargement
DDX for mesenteric torsion?GDV
Acute splenic torsion
GI obstruction
3 ways to Dx mesenteric torsion?(1) Radiography - entire small intestine distended w/ gas
(2) Ultrasound
(3) Sx or necropsy
How would you surgically Tx mesenteric torsion?Untwist & reposition the intestine (slowly!) → Allow time for reperfusion (slowly!), then evaluate viability → Resect devitalized tissue if possible → Lavage, peritoneal drainage
What is your time frame for surgically Txing mesenteric torsion?60 MIN! time is life!
What should you keep in mind if you need to resect a large portion of small intestine?Loses most of small bowel = short bowel syndrome. If PTx survives, will need to adapt diff kinds of feeding till intestine re-accommodated to quasi-normal Fxn
Where will you want to start resecting if there is mesenteric portion?Need to go until you find some pinkish tissue you can try to pic, red circle is where WEAK point is, need to go 4-5cm more to get a good anastomoses
In most cases of mesenteric torsion, which parts of the intestine are usually non-viable by the time of Sx?Jejunum & ileum (you will prolly have to do a MASSIVE resection)
Major consequence of resection & anastomoses is...Short bowel syndrome
Why should you be cautious about untwisting the mesenteric torsion?Reperfusion injury may be lethal

Surgical techniques

Question Answer
What are the 4 surgical techniques you can use on the intestines for the various problems already discussed?(1) Enterotomy
(2) Intestinal resection & anastomosis
(3) Serosal patching
(4) Intestinal plication (he doesnt like this one)
What are the 3 indications for a enterotomy?(1) Removal of intraluminal foreign bodies
(2) Full-thickness biopsy samples of intestine
(3) Evaluation of intestinal mucosa to determine intestinal viability
What is the surgical technique (steps) for performing an enterotomy? (OPENING)Atraumatically occlude intestine proximally & distally to prevent leakage → Make a stab incision into the lumen, extend w/ scalpel or Metzenbaum scissors → Make incision in healthy tissue, usually distal to foreign body
W/ an enterotomy, where/what kinda tissue do you want to make your incision in?HEALTHY tissue, usually DISTAL to FB
How long would you want to make your incision into the abd wall for an enterotomy?Long, but not as long as for an exploratory
Which retractor would you prolly want to use for an enterotomy & why?Belfour, bc good exposure
Do you need stay sutures for enterotomy?No
How do you non-traumatically occlude intestine if you have an assistant? If you are alone?Assistant: they can use index & middle fingers to clamp intestine to occlude lumen to make sure no intestinal content doesnt come out (never index & thumb!). If alone can work w/ doyen forceps - dont use tip - use bellow where have more elasticity.
If you are able to milk the FB around in the intestine, where should you make your incision & your sutures?If can milk FB, have incision farther down so suture healthy tissue...suture part that hasnt been harmed by FB. Unless you have no choice
Is the dilated loop of bowel the bowel prox or distal to the FB?Prox (so make your incision distal, in the healthy tissue)
What is the surgical technique (steps) for performing an enterotomy? (CLOSING) (What kinda suture? what technique? How can you help prevent reduction in diameter?)Close w/ simple continuous or simple interrupted sutures, w/ each suture being placed 2-3mm from edge of tissue, 2-3mm apart & should appose the mucosa accurately!. To increase diameter of lumen, close transversely, placing 1st suture at ends of incision
All sutures should go through what layer?Submucosa!
Which type of forceps are recc for intestines? Which arent?Recc ATRAUMATIC DeBakey forceps...Adson brown & rat tooth are not recc
If you handle intestines too rough, what can happen?Hematomas
Explain how to do water testLoad syringe w/ 6-10ml saline, clamp intestines, inject saline, intestine is low pressure system so dont need to do super high pressure. So inject 5, 6, 8 cm water btwn clamped portions, squeeze gently, look for any leaks. If leaks, you will have to apply another stitch & repeat water test. Dont put pressure when injecting water.
Can you close intestines w/ staples?Yes
What is the surgical technique (steps) for performing an enterotomy? (CHECKING AFTER CLOSURE)After suturing is complete, saline is injected into the lumen to test the incision for leakage (Water test). If a leak is seen, additional sutures are placed as necessary. The greater omentum is brought to the site of enterotomy & wrapped around the intestine
If youre patching your suture w/ the omentum, how will you make the omentum stay?Place some not perforating stitches around intestines to keep omentum on site.
The 4 Indications for Enterectomy?(1) Removal of non-viable (necrotic or ischemic) intestine
(2) Removal of irreducible intussusceptions
(3) Removal of traumatized intestine
(4) Removal of solitary neoplasms & fungal lesions
The worst bones for intestines are?Pig bones - hard & sharp
What is a good predictor of the ability of a piece of intestine to recover?If you can see the pulse around the mesenteric border
If you're really not sure if any of the tissue is vital anymore, how can you test it?Gently scrape serosal surface by mesenteric border - see if there is blood or anything
How can you test if the intestine has any motility?Gently pinch - this should start a wave of peristalsis
How can you check if there is edema in the intestines? What is this test called?Gently squeeze - see if there is any pitting when you release (godet edema test)
What are the 5 criteria for eval intestinal viability?(1) Color
(2) Wall texture & thickness
(3) Motility
(4) Pulsation of mesenteric arteries
(5) Bleeding of sero-muscularis when incised
What ANx tool can you use to assess intestinal viability? What is "normal"?Pulse oxymetry -normal intestinal saturation should be w/in 1 cm of normal peripheral O2 saturation
If you see this, what do you think happened? This is a trail of damage left by a sharp FB dragging through the intestines
What kinda dye can you use to assess intestinal viability? How?Fluorescein dye (IV) - accurate in detecting non-viable bowel, inaccurate in detecting viable bowel
If you are suturing in a simple continuous pattern, how far around can you go?Cant go more than 180° w/ simple continuous on resection anastomosis, bc 360 will be rigid, wont dilate, cz stricture or blockage
Enterectomy - Surgical Technique (which suture technique?)Standard technique is end-to-end approximating pattern using simple interrupted or simple continuous suture (only 180°, NOT 360°). It is technically easy & Maximizes luminal diameter & Results in rapid mucosal regeneration
Enterectomy - Surgical Technique (PROCEDURE)The mesentery is divided (pierce holes in windows) → The mesenteric vessels to segment of intestine to be removed are ligated → 2 clamps are placed on each side of the area of resection & the intestine is transected w/ scalpel or scissors. [*be sure that you re-sew the mesentery back together & don't leave holes in the windows, or bowel can herniate through it]
Enterectomy - Surgical Technique - which clamps do you use on the preserved portion of the intestine? Which do you use on the part to be removed?Atraumatic intestinal clamps are used on the conserved intestine (Doyens), Crushing clamps may be used on the section to be removed
**What should the angle you cut be like for the resection & anastomosis?ANTIMESENTERIC SIDE SHORTER THAN MESENTERIC SIDE **need angulation related to mesenteric border - place oblique 45-60° angle. If straight, impair blood supply to ANTImesenteric border
Aside from preserving the mesenteric blood supply to the antimesenteric side of the intestine, what other benefit is there to cutting the resected portion of the intestines at a 45°-60° angle?Make this diameter a little bigger (elliptical lumen) so if there is a mismatch, the ends of intestine, can still suture
Do you want to start your suture on the mesenteric or on the antimesenteric border? Why?Start 1st single suture on mesenteric border (simple interrupted) & then 2nd single suture on antimesenteric. Why? Bc on mesenteric side there is a lot of fat & hard to make bite through submucosa. So mesenteric 1st bc you can SEE that you got the submucosa bc the other side still open to see through. Then start making more single interrupted on each side.
Does leakage usually start from anti-mesenteric or mesenteric side?Usually mesenteric side
When closing the intestine, what is an awesome trick to allow yourself to manipulate the intestine w/ minimal trauma?After 2 sutures placed for closure, leave tags long & can then manipulate intestines.
3 things you can do when there is an End-to-end anastomosis you need to do w/ disparity in lumen size(1) Transect small segment at acute angle, large segment at more obtuse angle
(2) Space sutures in large segment farther apart
(3) Incise ***antimesenteric border of smaller segment to spatulate or ‘fish-mouth’ smaller segment
What is this technique? Explain This is the "fishmouth" technique. Grab smallest diameter & w/ scissors make incision to cut through antimesenteric border & then will amplify/enlarge small opening. Then place 1st suture from angle of incision & then bring to opposite side & will expand & match opposite side
If there is just a minor disparity btwn sized of resections, what can you do that is less invasive than fishmouth technique?Pinch the bigger one, will cz some peristalsis, it can shrink a little bc of that. If too much mushroom effect, remove some of the mucosa (only mucosa) so you make sure youre not getting sutures in the wrong place.