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SA Sx - Intestines 3

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drraythe's version from 2017-09-15 00:39

Sx Techniques cont…

Question Answer
Enterectomy - Surgical Technique (CLOSURE)The mesenteric border is sutured 1st!!! Then, The 2nd suture is placed in the antimesenteric border (bc doing 2 that go 180°, not 1 that goes 360°), then The remaining sutures are placed 2-3 mm from the edge of tissue & 2-3 mm apart
Explain what you must know if you are going to cut/pierce a hole in the mesentery & what you must do afterYou will NEED to suture it closed again so bowel doesnt herniate through it & get constricted. The mesentery often rolls up so you will need to wet your fingers & unroll it before you suture.
Which type of suture & in what fashion do you close the mesentery?The mesentery is sutured w/ 3-0 or 4-0 absorbable suture, simple interrupted or simple continuous (maybe 5-0), not too much tension!
So, the disparity btwn the resections is too big for just pinching to induce shrinkage by peristalsis & then it's also too big to fix via fishmouth technique. What else can you do? (Any risks associated w/ it possibly?)You can partially close bigger diameter side's edges to itself until you have opposed to smaller side. Food might get stuck in the little pouch that might be created by this technique, but often peristalsis flattens it out
What are 3 choices you have on how to anastomose your 2 resections of intestines?End to end, side to end, side to side
Explain the serosal patch technique (basic w/ pic)where we have enterectomy site already repaired & dont like the closure & omentum wont fit through, use serosal patch. Serosa provided by adjacent loops of bowel. Make loops wide enough so no hair pinning problems. Sew it to it BUT DONT PENETRATE LUMEN.
Indications for serosal patching?(1) Questionable area of suturing after enterotomy or anastomosis: Tension at suture line, Damage to serosa, Repair of dehiscence
(2) Superficial trauma to intestinal wall
*When does dehiss usually happen? When does Infnxn usually happen?Both are at about 3-5d
Surgical technique for serosal patching (step by step)placement of an antimesenteric border of the small intestine over a suture line or organ defect → adjacent loop of intestine is sutured over damaged area → sutures engage submucosa but do not penetrate the mucosa. → *avoid twisting, stretching or kinking the intestine & mesenteric vessels
What are the 2 kinds of stapled anastomoses?(1) Side-to-side (Fxnal end-to-end)
(2) Inverting end-to-end (often staplers used in large & expensive animals)
Explain the side-to-side stapled anastomoses - which stapler? How’s it done?GIA & TA staplers
Explain the end-to-end (inverting) stapled anastomoses - which stapler? How’s it done?EEA stapler
Intestinal plication is aka?Enteroenteropexy
What is the reasoning behind why we do an intestinal plication?Developed to prevent recurrence of intussusception...however, Efficacy questionable
How do you do enteroenteropexy (plication)?Small intestine is placed in gentle loops & seromuscular layers are sutured w/ small interrupted sutures
What is a colopexy done for?Colopexy is done to prevent caudal displacement of the colon & rectum. Especially useful in animals w/ recurrent rectal prolapse (also useful for helping prevent perineal hernias)
Which side of the body is the colopexy done on? If you want to do a cystopexy too (attach bladder to wall) where do you do THAT?Colopexy on L (bc colon on the left)....cystopexy then on R, bc don't want 2 pexys on the same side
What type of suture do you wanna use for a colopexy?Prolene or nylon so it'll stay for a long time
Who is at risk for perineal hernias? What structures do you wanna pexy to try to fix it?Colopexy, cystopexy & deferentopexy (use deferens) usually PTx w/ perineal hernias is intact male dogs. 3x times recurrence if not castrated
How do you pexy the colon to the abd wall? (Technique)On LEFT abd wall, 1st suture the back wall 1st, then the front wall. Remember length you should have - non less than like 2.5 or 3.5 cm in length to have a good adhesion
Postop care → when do you wanna try to give PTx water?Offer water 6-8 hours after Sx
Postop care → when do you wanna try to give PTx food?If no vomiting occurs, offer bland food 12-24 hours after Sx (asap bc enterocytes need glucose). Reintroduce normal diet gradually starting at 48 hours after Sx
Do you wanna give ABx post-op?NO ABX unless peritonitis is present
For the incisional colopexy, you need it to be how long & *what layers do you cut?Need it to be 3.5cm long!!! Otherwise not strong enough. Cut into ***seramuscularis only, NOT INTO LUMEN!!!!
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Complications

Question Answer
#1 reason for Sx complications of intestinal Sx?Poor suture technique! ALWAYS MAKE SURE SUBMUCOSA IS ENGAGED
Never use what kinda suture on intestines?Chromic gut
Dehiscence & peritonitis usually due to what 4 probs?Result of poor suturing technique, non-viable bowel, use of chromic gut, delayed healing
When does Dehiscence & peritonitis usually occur? (What is the rate of dehis in SI?)Occurs btwn 3rd & 5th day after Sx. Rate of dehiscence of small intestine = 16%
How dangerous is intestinal dehiscence?75% of PTxs w/ intestinal dehiscence die - treat aggressively!!
Why can Dehiscence & Peritonitis lead to adhesions?Adhesions bc serosa will move over & cover to try to help.
Some ways to maybe help avoid dehiscence/peritonitis?Use aseptic tech
Change gloves
Make sure suture in submucosa
use diff instruments to close
What are 3 common int. Sx complications?Ileus
Adhesions
Stricture
How can you minimize risk/severity of Ileus?Frequent feeding of small meals & early ambulation decrease severity
What mistakes are usually done which cz strictures?Rare, associated w/ inverting or everting suture pattern or excessive tension
*Dogs w/ 2 or more of the following risk factors are predicted to be at high risk for developing anastomotic leakage...(3)Preoperative peritonitis
intestinal foreign body
Serum albumin concentration ≤ 2.5 g/dL.
Short bowel syndrome happens when _________(amt)_________ of SI has been removed70-80%
CS of short bowel syndrome?Weight loss
Diarrhea
Malnutrition
Anemia 2° to folic acid deficiency
How do you Tx short bowel syndrome?Supportive therapy until remaining intestine adapts (1 - 2 mos)
Apprx how long does it take to have bowels adjust to short bowel syndrome?1-2mo
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Neoplasia

Question Answer
Neoplasia of the Intestine → most common location in dogs? Cats?DOGS: colon & rectum. CATS: SI
Are most intestinal tumors benign or malig?Malig
How common is metastasis at necropsy?86% of dogs & 71% of cats have metastasis at necropsy (lymph nodes, liver, lungs) (really high!)
Most common intestinal malignancy of dog?*Adenocarcinoma
Most common RECTAL tumor of dog?Adenomatous polyp
Most common intestinal tumor of cats?*Lymphosarcoma (benign tumors rare)
Mean age for a dog w/ Intestinal Adenocarcinoma? Cat?DOG: 9yr
CAT: 10yr
What is the gender ratio like for Intestinal Adenocarcinoma in dogs? Cats? [M:F]DOG: 21:11
CAT: 5:9
(SO, more BOYS in DOGS & more GIRLS in CATS)
Which breeds of dogs are more prone to intestinal adenocarcinoma? Cats?DOGS: Boxers, Collies, German shepherd dogs
CATS: Siamese
Hx & signalment of a SMALL intestine neoplasia?Weight loss
Anorexia
Depression
Diarrhea
Signs of obstruction
Inclding vomiting
Hx & signalment of a LARGE int neoplasia?Tenesmus
Hematochezia
Dyschezia
Weight loss
Which int neoplasia can cz anemia?Leiomyosarcoma
What are some things you'd see upon exam which might point to intestinal neoplasia?Palpable abdominal or rectal mass
Dilated loops of intestine (obstruction)
Anemia (leiomyosarcoma)
Signs of peritonitis (w/ perforation of gut or necrosis of tumor)
How will intestinal neoplasia appear on radiographs?Abdominal mass
Dilated intestinal loops
Contrast radiography (Intramural or annular lesion, Diffuse filling defects in bowel wall)
Classic radiographic lesion of intestinal neoplasm?NAPKIN RING
What might clue you toward intestinal neoplasia on US?Enlarged lymph nodes or hepatic masses
Intestinal Neoplasia therapy has what 2 options?(1) Intestinal resection & anastomosis
(2) Chemo
When is Intestinal resection & anastomosis recommended as a Tx for neoplasia? (3 criteria)(1) Single mass
(2) Resection < 70% of small intestine
(3) No metastatic lesions present
When is chemo effective as a Tx for int neoplasia? Not so much?Lymphosarcoma: some success. Adenocarcinoma: poor results
Recc Tx for Rectal polyps? (Where usually ARE the polyps?)Submucosal resection per anus - most are w/in 2 cm of anus (look like stalks of broccoli usually)
Therapy of Colorectal Neoplasia which is Annular or more cranial can be Txd w/ what 3 types of Tx?(1) Dorsal approach to rectum
(2) Rectal pull-through approach
(3) Ventral approach to rectum
What kinda special tool can you use to remove polyp & seal off tissue?Ligasure™ forceps (kinda like a high tech electric scalpel)
If you are removing rectal polyps & the such, what medication is super helpful that you shouldnt forget about?Suppositories!
What is this approach? Rectal pull-through approach
How do you "pull through" the rectum to the outside in the rectal pull through approach?Use stay sutures to pull out
If there is a mass in the rectum & you are using rectal pull through technique - what kinda biopsy do you use? What kinda incision do you make for this, then? What would you safety margin be like?You would do an EXCISIONAL biopsy using an ELIPTICAL incision w/ a MINIMAL safety margin *dont forget to send sample in for path
If you have performed an excisional biopsy via rectal pull through technique, what are some things you should do post-op to help it heal?Low residue diet & stool softeners
What is this procedure? When do you use it? What are the red dots about? This is a dorsal/ventral approach. It is used to access Annular or more cranial tumors in the colo-rectal area. If ventral, need to cut floor of pubis to access colo-rectal area. The red dots are where you could drill to place orthopedic wire to replace the pubis you cut away
Why must you handle the colo-rectal region w/ care?Careful w/ stretching vessels...no 1° or 2° acurates in Lg bowel.
What is the prog of Colorectal tumors? Likelihood of recurrence?Large or sessile tumors more likely to recur. Euthanasia, usually bc of failure to control dyschezia (painful defecation) or hematochezia (try to see if there is a bleeder & why is it bleeding. colon is difficult area.)
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